
Class J5l^-^M_ 

Book ^1 %<{ 

Copyright )j _ 



COPYKIGHT DEPOSIT, 



A MANUAL 



OF 



OSTEOPATHIC GYNECOLOGY. 



BY 



PERCY H. WOODAI.lv, M.D., D.O., 

• \ 
PROFESSOR OF SYMPTOMATOLOGY, GYNECOLOGY AND OBSTET- 
RICS, SOUTHERN SCHOOL OF OSTEOPATHY, AND 
SUPERINTENDENT OF SOUTHERN INFIRMARY 
OF OSTEOPATHY, FRANKLIN, KY. 



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NASHVILLE, TENN. 
Jno. Rundle & Sons Printers and Publishers. 

1902. 



THF LIBRARY OF 

PK£ RECEIVED 

- 

Onpv^kWT ENTRY 

Ct XXa No. 
COPY 3. 



alV 



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1902 

COPYRIGHT APPLIED FOR BY 

DR. PERCY H. WOODAI,!, 



CONTENTS. 



CHAPTER I. 

Anatomy. 

Pelvic Bones. Articulations. Muscles. Fascia. 
Peritoneum. Perineum. Uterus — Size, Position, 
Mobility, and Ligaments. Ovaries. Fallopian 
Tubes. Vagina. Vulva. Nerve Supply to Female 
Generative Organs. 

CHAPTER II. 

Examination. 

Anamnesis or Oral Examination. Osteopathic 
Examination — Muscular and Ligamentous Contrac- 
tures, Osseous Lesions. Physical Examination — 
Position, Inspection, Palpation, Percussion, Aus- 
cultation, Mensuration. Vaginal Examination — 
Condition of Vaginal Walls, Condition and Direc- 
tion of Cervix. Bimanual Examination of Uterus, 
Ovaries, and Tubes. 



IV 

CHAPTER III. 



Intravaginal or Local Treatments. 

Position. Technic. Force. Frequency. Contra- 
indications. 



CHAPTER IV. 
Menstruation. The Menopause. 

CHAPTER V. 

Disorders of Menstruation. 

Precocious Menstruation. Vicarious Menstrua- 
tion. Amenorrhoea. Dysmenorrhoea. Menorrha- 
gia. Metrorrhagia. Leucorrhoea. 

CHAPTER VI. 

Diseases of the Vulva. 

Malformations. Hermaphrodism. Cutaneous 
Affections. Vulvitis. Pruritus Vulvae. Urethral 
Caruncle. Venereal Warts. Chancroid. Cysts 
and Abscess of the Vulva-vaginal Glands. Labial 
Varicocele. Pudendal Hydrocele and Hernia. Tu- 
mors. Injuries. 



V 

CHAPTER VII. 
Diseases of the Vagina. 

Malformations. Vaginitis. Vaginismus. Fis- 
tulae. Prolapse of the Vaginal Walls. Injuries. 
Foreign Bodies in the Vagina. 

CHAPTER VIII. 

Diseases of the Uterus. 

Malformations. Acute Endometritis. Chronic 
Endometritis. Lacerations of the Cervix. Subin- 
volution. 

CHAPTER IX. 

Displacements of the Uterus. 

Anteflexion. Anteversion. Backward Displace- 
ments. Prolapse. 

CHAPTER X. 

Neoplasms of the Uterus. 

Fibroid Tumors. Malignant Tumors — Carci- 
noma and Sarcoma. 



VI 

CHAPTER XI. 

Diseases of the Ovaries. 

Defective Development. Congestion. Displace- 
ments. Prolapse. Acute Ovaritis. Chronic Ova- 
ritis. 

CHAPTER XII. 

Neoplasms of the Ovaries. 

Simple, Proliferating, and Dermoid Cysts. Solid 
Tumors. Fibroid Tumors. Sarcoma. Carcinoma. 

CHAPTER XIII. 

Diseases of the Fallopian Tubes. 

Acute Salpingitis. Chronic Salpingitis. Hydro 
salpinx. Pyo-salpinx. 

CHAPTER XIV. 

Diseases of the Tissues of the Pelvis. 

Pelvic Peritonitis. Pelvic Cellulitis. Pelvic 
Hemorrhage. 

CHAPTER XV. 
Ectopic Gestation. 



PREFACE. 



An effort has been made to present osteopathic 
gynecology to the student and practitioner in the 
most practical and helpful manner. All that is not 
in accord with the best osteopathic authority and 
with the known facts of anatomy, physiology, and 
pathology has been eliminated. From the authori- 
ties on these subjects many points of particular os- 
teopathic interest hitherto not incorporated into 
osteopathic literature have been introduced. 

The examination of a patient — oral, osteopathic, 
physical, and pelvic — is minutely described. 

The osteopathic causes of female diseases are 
brought prominently forward, the symptoms are 
fully given, and the diagnosis of such diseases im- 
pressed upon the reader. 

The treatment of each disease is complete, and is 



VIII 

that which is the outgrowth of experience and that 
which is dictated by scientific principles and com- 
mon sense. A special chapter is devoted to local 
or intravaginal treatments, for the reason that they 
are of great benefit in the treatment of pelvic dis- 
eases and because osteopathic literature is lacking 
in regard to them. Particular attention is given to 
the method, force, frequency, and contraindications 
for such treatments. 

Menstruation — its disorders, their cause and 
treatment — and the menopause and its management 
have received proper consideration. 

This effort to add something of value for the ben- 
efit of the profession is respectfully submitted to 
the consideration of all legitimate osteopaths. 

PERCY H. WOODALL, M.D., D.O. 



CHAPTER I. 



Anatomy. 

Since we shall limit our consideration to the pel- 
vic organs, the discussion will be confined to the 
structure of the pelvis and its contents. No de- 
tailed description will be attempted, but only those 
points of especial osteopathic significance will be 
commented upon. 

The pelvic skeleton is formed of four bones — 
two ossa innominati, bounding it laterally and an- 
teriorly, and the sacrum and coccyx, bounding it 
posteriorly. These four bones form four articula- 
tions with each other — two sacro-iliac, one pubic, 
and one sacro-coccygeal. They also form three ar- 
ticulations with other bones — two ilio-femoral and 
one lumbo-sacral. 

The sacroiliac articulations are amphiarthrodial 
joints, and are formed by the sloping auricular sur- 
faces of the sacrum and of the ilium. Each of 
these surfaces is covered with cartilage; and it is a 



10 

significant fact that while these cartilages are in 
close contact, they are, as a rule, not united, and, 
in rare instances, are separated by small cavities 
containing a fluid resembling synovial fluid. The 
chief bond of union between the bones is the sacro- 
iliac and sacro-ischial ligaments. Of the sacro- 
iliac ligaments there are two — an anterior, consist- 
ing of thin ligamentous bands, connecting the an- 
terior surfaces of the sacrum and ilium, and a 
posterior, composed of strong interlacing bands, 
uniting the rough posterior surface of the sacrum 
to the rough surface of the ilium behind the auric- 
ular surface. This ligament forms the strongest 
connection between these bones. 

The sacro-ischial ligaments are the greater and 
the lesser sacro-sciatic. The greater sacro-sciatic 
ligament is continuous with the posterior sacro- 
iliac ligament, and unites the posterior surface and 
lateral margins of the sacrum and coccyx to the 
posterior inferior spine of the ilium and to the in- 
ner margin of the tuberosity and ramus of the 
ischium. This ligament is pierced by the coccy- 
geal nerve and the coccygeal branch of the sciatic 
artery. The lesser sacro-sciatic ligament stretches 
across from the spine of the ischium to the lateral 
margins of the sacrum and coccyx, anterior to, and 
intermingled with, the fibers of the greater sacro- 
sciatic ligament. 



11 

These two ligaments convert the sacro-sciatic 
notches into foramina, the greater sacro-sciatic 
foramen being above the lesser ligament and the 
smaller below it. Through the greater sacro-sciatic 
foramen pass out the gluteal vessels, the supe- 
rior gluteal nerve, the pyriformis muscle, the sci- 
atic vessels and nerves, the internal pudic vessels 
and nerve, and muscular branches from the sacral 
plexus of nerves; through the lesser sacro-sciatic 
foramen the obturator externus muscle and its 
nerve pass out and the internal pudic vessels and 
nerve pass in. This articulation is supplemented 
by the erector spinae muscle posteriorly and by the 
psoas magnus anteriorly. 

This joint, by reason of its sloping articular sur- 
faces, its entirely ligamentous union, its mobility 
(which is so great in some cases during the latter 
months of pregnancy as to impede locomotion), 
and the part it has to bear in sustaining the weight 
of the body and the violence of shock in walking, 
in jumping, and in falls upon the feet, is very sus- 
ceptible of subluxation, and should receive the clos- 
est attention in every examination. Its nerves are 
from the posterior-sacral and lumbo-sacral cords. 

The pubic articulation is an amphiarthrodial 
joint, formed by the opposing surfaces of the pubic 
bones ; an interpubic disc ; anterior, posterior, supe- 
rior, and subpubic ligaments, 



12 

The sacro=coccygeal articulation is a movable 
joint, formed by the apex of the sacrum and the base 
of the coccyx. It is supplied with anterior, poste- 
rior, lateral, and interarticular ligaments and a fibro- 
cartilage. Many subdislocations occur at this 
joint. It is supplied by the fourth and fifth sacral 
nerves, the coccygeal, and probably the second and 
third sacral nerves. 

The lumbosacral articulation is amphiarthrodial, 
and is formed by the fifth lumbar vertebra and the 
base of the sacrum. It is furnished with the liga- 
ments common to the vertebral joints, and, in addi- 
tion to these, has a lumbo-sacral and an ilio-lumbar 
ligament. 

The lumbo-sacral ligament is continuous with 
the anterior sacro-iliac ligament, and passes out- 
ward and downward from the front part of the 
transverse process of the last lumbar vertebra to 
the lateral surface of the base of the sacrum. 

The ilio-lumbar ligament connects the apex of the 
transverse process of the last lumbar vertebra to 
the crest of the ilium directly in front of the sacro- 
iliac articulation. This joint is supplied by the 
fourth and fifth lumbar nerves. 



Thi~ iliofemoral articulation", while it is not one 
of the so-called " pelvic articulations," is still very 
important to us, for the reason that it and the struc- 
tures surrounding it are intimately connected with 



13 

the pelvic viscera through the lumbar and sacral 
plexuses of nerves. Because of this, disorders of 
this joint or the contiguous structures may reflexly 
seriously affect pelvic function. This is an enar- 
throdial joint, formed by the head of the femur and 
the acetabulum of the innominate bone. The joint 
is supplied with a capsular ligament, which, in 
broad terms, arises from the margin of the acetabu- 
lum and surrounds the neck of the femur below. 
Reinforcing this is the ilio-femoral, or Y-shaped 
ligament, which, arising from the anterior inferior 
spine of the ilium and descending like an inverted 
Y, is attached by one arm to the lower part of the 
anterior intertrochanteric line, while the other arm 
is attached to the upper part of this line and to the 
neck of the femur. 

Besides these, there are the cotyloid ligament, 
forming a cartilaginous rim around the acetabulum, 
making it deeper; a transverse ligament, bridging 
across the cotyloid notch; and the ligamentum 
teres, arising from the cotyloid notch and attached 
to a depression on the head of the femur. 

This joint is supplied by the obturator, the ac- 
cessory obturator, the anterior crural, the great 
sciatic, and the nerves to the obturator internus 
and quadratus femoris muscles. These nerves re- 
ceive filaments from the first lumbar to the third 
sacral nerves. 



14 

Of the muscles attached to the pelvic bones, three 
deserve particular attention — the pyriformis, the 
psoas magnus, and the levator ani. 

The pyriformis assists in forming the posterior 
and outer wall of the pelvic cavity. It arises by 
three digitations from the anterior surface of the 
sacrum, from the ilium below the posterior inferior 
3pine, and from the anterior surface of the great 
sacro-sciatic ligament. Passing out from the pel- 
vis through the great sacro-sciatic foramen, it is in- 
serted into the upper border of the great trochanter 
of the femur. The sacral plexus rests upon the an- 
terior surface of this muscle. The anterior divi- 
sions of the sacral nerves going to form the sacral 
plexus pass between the digitations of the pyri- 
formis and are subject to pressure in contracture 
of the muscle. It is also in close relationship with 
the internal pudic nerve, which passes out of the 
pelvis through the great sacro-sciatic foramen be- 
low the muscle. 

The psoas magnus arises from the lumbar verte- 
brae, the last dorsal, and the lumbar intervertebral 
discs by five slips, which are connected to each 
other by tendinous arches. With the tendon of 
the iliacus it is inserted into the lesser trochanter 
of the femur. This muscle is deserving of special 
notice, since, passing beneath the tendinous arches, 
connecting its different slips, are the sympathetic 



15 

nerves, connecting the lumbar ganglia with the spi- 
nal nerves, and in the posterior portion of the mus- 
cle substance is placed the lumbar plexus. Con- 
tractures of this muscle are, therefore, of especial 
significance. 

The levator ani with the coccygeus and the pel- 
vic fascia, constitute the pelvic diaphragm, form a 
part of the floor of the pelvis, and aid in maintain- 
ing the pelvic organs in their proper position. This 
muscle arises from the posterior surface of the body 
and ramus of the os pubis, external to t4ie sym- 
physis; from the inner surface of the spine of the 
ischium; and between these points from the angje 
of division between the obturator and recto-vesical 
layers of the pelvic fasciae. The fibers from each 
side pass downward toward the median line. The 
anterior extend along the vagina, and are connected 
to it by connective tissue, but do not terminate in 
its walls. The middle portion of the muscle sur- 
rounds the rectum. Some fibers are inserted into 
it, others blend with those from the opposite side, 
while the most posterior fibers are inserted into the 
sides of the apex of the coccyx. The coccygeus 
muscle is behind the levator ani, and is continuous 
with it at its origin and insertion. 

The pelvic fascia is a continuation of the iliac and 
transversalis fascia, and is attached along the brim 
of the pelvis and to the inner surface of the bone 



16 

along the origin of the obturator internus. Pass- 
ing backward on each side, it covers the pyrifor- 
mis and the sacral nerves until it reaches the front 
of the sacrum. Anteriorly it is attached along the 
origin of the obturator internus, assists in bound- 
ing the inner opening of the obturator canal, and 
at the lower part of the symphysis pubis is attached 
to the anterior pelvic wall. Between the lower part 
of the symphysis pubis and the spine of the ischium 
the fascia is thickened and whitish, forming the so- 
called " white line," which marks the insertion of 
the levator ani and the division of the fascia into 
three layers, two of which invest the muscle, while 
the third adheres to the pelvic wall and covers the 
obturator internus muscle and is called the " obtu- 
rator fascia." The layer of fascia covering the leva- 
tor ani is the recto-vesical fascia; the layer beneath 
the muscle is the ischio-rectal, or anal, fascia. 

Lying on this fascia and beneath the peritoneum 
is a variable amount of loose connective tissue, 
which may be said to serve as a cushion for the 
viscera and a support for their blood vessels. This 
tissue is most abundant at the sides of the upper 
portion of the vagina and the cervix. It constitutes 
a large part of the uterine ligaments, and in it are 
a large number of blood vessels that are distended 
in any condition, causing pelvic congestion. This 
connective tissue is frequently the seat of inflam- 



17 

matory effusions and exudates, which may become 
organized and form cicatricial bands. Such bands 
are one of the most frequent causes of uterine dis- 
placements. When not of sufficient extent to cause 
displacements by their presence, they so constrict 
and impinge upon blood vessels and nerves as to 
disturb their function and cause other diseased 
conditions. These cicatricial bands, or adhesions, 
osteopathically considered, are of the greatest etio- 
logical significance. 

The pelvic peritoneum is a continuation of that 
lining the abdominal cavity. Posteriorly it passes 
downward, covering the pyriformis muscle and the 
sacral nerves, and embraces the upper third of the 
rectum. Passing farther down, it covers the ante- 
rior surface of the middle third of the rectum, from 
which it passes to the floor of the pelvis and on to 
the upper part of the posterior surface of the vagina, 
forming, as it passes from the rectum to the vagina, 
Douglas' pouch. The peritoneum is now reflected 
over the uterus, covering all of its posterior surface 
and the anterior surface as far down as the cervico- 
uterine angle. The folds of peritoneum passing up 
over the posterior surface of the uterus and that 
covering the anterior surface, as they are reflected 
over the Fallopian tubes, form the broad ligaments. 
After leaving the uterus, the peritoneum passes to 
the bladder, covering its posterior and superior sur- 



18 

faces, from which it is reflected to the anterior ab- 
dominal walls. 

The peritoneum is subject to inflammations, and 
its inflamed surfaces readily become adherent and 
form adhesions between the uterus and the sur- 
rounding viscera. These are a frequent source of 
displacement or other pathological condition. 

The structures previously described are further 
strengthened by those of the perineal region, which 
comprises the tissues between the levator ani and 
the integument within the space bounded by the 
rami of the os pubis and ischium, the tuberosities 
of the ichii, the lower edge of the gluteus maximus 
muscle, and the tip of the coccyx. These tissues 
consist of integument, adipose tissue, and three lay- 
ers of fascia, between which are found four pairs of 
muscles, besides blood vessels and nerves. Be- 
neath the skin is found the usual layer of subcuta- 
neous areolar and fatty tissue, which is continuous 
with that of neighboring parts. Next in order is 
the superficial perineal fascia, or the first fascial 
layer, a continuation of the obturator fascia pre- 
viously described. All three of these layers of fas- 
cia have the same anterior attachment — the rami 
of the os pubis and ischium. Between the first 
layer, or the superficial perineal fascia, and the sec- 
ond layer, or the superficial layer of the deep peri- 
neal fascia, are situated three pairs of muscles — 



19 

the erector clitoridis, the sphincter vaginae, and the 
superficial transverse perinaei. The second layer, 
or superficial layer of the deep perineal fascia, 
passes backward to the posterior border of the 
transversus perinaei. It joins the superficial peri- 
neal fascia and the third layer, or the deep layer, 
of the deep perineal fascia. Between the two lay- 
ers of the deep perineal fascia there is one pair of 
muscles — the constrictor urethrae, or the deep 
transversus perinaei. Beneath this muscle is the 
deep layer of the deep perineal fascia, which passes 
backward from its anterior attachment and joins 
the two other layers to form the transverse perineal 
septum, from which it is continued on the under sur- 
face of the levator ani, as the ischio-rectal, or anal, 
fascia previously mentioned. The union of these 
three layers of fascia forms the transverse perineal 
septum, which is further strengthened by a trans- 
verse fibrous band passing transversely across the 
pelvis from a point just anterior to the tuberosities 
of the ischii. 

The perineal body is the mass of tissue between 
the anterior rectal and the posterior vaginal wall. 
Its center corresponds to the middle of the trans- 
verse perineal septum, about one-half inch anterior 
to the anus. This point marks the convergence of 
the three layers of perineal fascia, the external and 
internal sphincters ani, the levator ani, the transver- 



20 

sus perinaei, and the sphincter vaginae muscles. 
This body forms a fixed and most important point 
of support for the pelvic floor and serves to main- 
tain the rectum and vagina in their relative posi- 
tions. 

The perineal region receives its nerve supply from 
the anterior divisions of the fourth and fifth sacral 
nerves, the coccygeal nerve, and the pudic nerve, 
which receives its fibers from the second, third, and 
fourth sacral, and, according to some authorities, 
from the first and fifth sacral also. The integument 
is also supplied by branches from the small sciatic. 

The uterus is a flattened, pear-shaped organ, con- 
taining a small cavity, which opens below into the 
vagina and above, at each angle, into the Fallopian 
tube of the corresponding side. It is divided into 
a fundus, a body, and the cervix. The fundus is that 
portion above the opening of the Fallopian tubes. 
The cervix is the lower portion of the organ that 
projects into the vagina. It comprises nearly half 
the total length of the uterus and has a fusiform 
cavity, which opens into the vagina through a trans- 
versely oval orifice, called the " external os " or 
the " os uteri." Above, the cavity of the cervix is 
constricted as it opens into the cavity of the body, 
the constriction forming the internal os. The body 
of the uterus is that part of the organ between the 
fundus and the cervix. 



21 

The walls of the uterus are composed of three 
layers. The external, or serous, layer is formed of 
peritoneum. The middle, or muscular, layer forms 
by far the greater part of the uterus, and is itself 
formed by three irregular layers of involuntary mus- 
cular tissue, which are held together by a small 
amount of connective tissue. The inner of these 
layers has a general longitudinal arrangement, the 
middle layer is circularly disposed, while the outer 
layer is arranged both circularly and longitudinally. 

The internal and lining layer of the uterus is of 
mucous membrane, and is called the " endome- 
trium." This is composed of a single layer of colum- 
nar, ciliated epithelial cells, which are placed di- 
rectly upon the muscular layer, the endometrium 
being peculiar in that it has no submucous connect- 
ive tissue layer. In this mucous membrane there 
are a large number of tubular glands dipping down 
into the muscular layer. These are the uterine 
glands, and are lined with epithelium similar to, and 
continuous with, that on the surface. Besides these, 
there are in the cervix mucous glands, whose ori- 
fices may become obstructed, forming small cysts, 
which are visible to the naked eye — the ovules of Na- 
both. In the body of the uterus the mucous mem- 
brane is smooth, but in the cervix there are small 
ridges of mucous membrane radiating obliquely 
from an anterior and posterior longitudinal ridge. 



22 

These are called the " arbor vitae." The mucous 
membrane of the lower part of the cervix is covered 
with stratified pavement epithelium continuous with 
that of the vagina. The most marked peculiarity 
of the uterine mucosa is that it is exfoliated with 
each menstrual period. 

The physician who has not by experience learned 
to recognize the normal size, position, and mobility 
of the uterus cannot hope to obtain success in prac- 
tice. 

Size. — The virgin uterus is a little less than three 
inches long, between one and one-half and two 
inches wide, and about one inch thick. After child- 
birth it remains somewhat larger than before, and 
after the menopause it again shrinks. When pal- 
pated through the vagina and abdominal walls, the 
organ seems larger than the dimensions given, 
owing to the thickness of the tissues through which 
it is felt. 

Position. — The fundus of the uterus rises to, or 
slightly above, the brim of the pelvis ; is directed 
forward and slightly upward ; is approximately in 
the median line ; and rests forward upon the blad- 
der. The long axis of the body of the uterus is 
nearly horizontal in the erect position and forms a 
slight angle with the axis of the cervical canal. The 
cervix is normally found in the middle of a line con- 
necting the ischial spines and points backward and 
slightly downward. 



23 

Mobility. — The uterus is an extremely movable 
organ, and is often found in positions which, if per- 
sistent, would be pathological ; in fact, it may be 
said that fixation of the uterus in any position is 
abnormal. It descends and rises with each respira- 
tory act, and is moved forward or backward by dis- 
tention of the rectum or bladder. Its mobility is 
such that in a normal condition it may be pressed 
against the lateral walls of the pelvis with very lit- 
tle or no pain or discomfort. 

Ligaments. — The uterus is supplied with eight 
ligaments, which contribute to its support and the 
maintenance of its position. These are two vesico- 
uterine ligaments in front, two sacro-uterine liga- 
ments behind, and one broad and one round liga- 
ment on each side. 

The vesico-uterine ligaments are formed of two 
folds of peritoneum that are reflected over the pelvic 
connective tissue lying between the bladder and the 
uterus. They are placed one on either side of the 
median line, and are attached to the uterus at the 
level of the internal os. 

The sacro-uterine ligaments are composed of un- 
striped muscular fibers continuous with those of the 
uterus, with fibrous and loose connective tissue, all 
of which is covered by peritoneum. They are at- 
tached to the anterior surface of the second and 
third bones of the sacrum, from which they run 



24 

downward and forward to the uterus, one on either 
side, and are attached at the level of the internal os. 
These ligaments, with the anterior vaginal wall, are 
said to form an elastic beam, upon which the uterus 
is suspended. In their normal condition these liga- 
ments prevent the uterus from being dragged be- 
yond the vaginal entrance. 

The broad ligaments are composed of loose con- 
nective tissue, unstriped muscular fibers, blood ves- 
sels, lymphatics, and nerves, covering which is peri- 
toneum. The muscular fibers are a continuation of 
the outer layer of the uterine muscle, and form a 
flat layer of fibers between the uterus, ovaries, and 
tubes. A band of these fibers follows the ovarian 
artery to the vertebral column. The broad liga- 
ments are attached by their inner margins to the 
sides of the uterus and, at their outer margins, to 
the sides of the pelvic walls, following a line begin- 
ning midway between the ilio-pectineal eminence 
and the sacro-iliac articulations, and running down- 
ward and backward to the level of the spine of the 
ischium, between the great sacro-sciatic notch and 
the obturator foramen. These ligaments, to a small 
degree, limit the lateral motion of the uterus ; and if 
the sacro-iliac ligaments have for any reason lost 
their tone, they assist in the support of the uterus. 

The round ligaments arise from the superior an- 
gles of the uterus, and, passing forward, upward, 



25 

and outward between the layers of the broad liga- 
ment, in front of and below the Fallopian tube, enter 
the internal abdominal ring, pass along the inguinal 
canal, and are lost in the labia majora. They are 
from four to five inches long, and consist of invol- 
untary muscle fibers from the uterus. These liga- 
ments are supplied by the genital branch of the 
genito-crural nerve, and are capable of electric stim- 
ulation. They are pierced through their center by 
a branch from the deep epigastric artery. The con- 
traction of both ligaments tends to tilt the uterus 
forward; and in coughing, lifting, straining, etc., 
their simultaneous contraction prevents retrover- 
sion. 

The ovaries are the organs contributing the ovum, 
the female element of reproduction. They are two 
flattened, elongated, oval-shaped bodies, measuring 
about one and one-half inches long, three-quarters 
of an inch wide, and about one-third of an inch 
thick. They are placed with their long axis almost 
vertical, their lower extremities being attached to 
the uterus by the ovarian ligament, while their up- 
per extremities are attached to the fimbriated ex- 
tremity of the Fallopian tube. By their anterior 
margins they are attached to the broad ligaments. 
The ovaries lie in a depression in the posterior layer 
of the broad ligaments, are slightly to the side and 
in front of the rectum, and are surrounded by the 



26 

small intestines. The peritoneum covering them 
loses its usual characteristics and becomes a layer of 
epithelioid cells. The position of the ovary varies 
according to the position of the uterus; but in all 
positions the Fallopian tube forms a loop around it, 
the inner half of the tube ascending obliquely over 
it, the outer half, with the dilated extremity, de- 
scending and bulging out behind it, from which the 
fimbriae pass to grasp it. In structure the, ovary 
consists of a stroma of fibrous connective tissue, in- 
voluntary muscle fibers, and blood vessels, inclosed 
in which are a large number of Graaffian follicles in 
all stages of development. The outer layer, in which 
the connective tissue is more compact, is called the 
" cortical layer/' and the outer and most compact 
layer of this is called the "tunica albuginea." Inside 
the cortical layer is found the medullary layer, in 
which the connective tissue is much less compact 
and the blood vessels more abundant. 

The Fallopian tubes are for the conduction of the 
ovum to the uterus. They are from three to five 
inches long. They begin at the superior angles of 
the uterus, pass out between the layers of the broad 
ligaments in a tortuous manner, and by their outer 
extremity embrace the ovary. The tubes have a 
very small canal for their inner half, which opens 
into the uterus through the ostium internum. 
Throughout their outer half their lumen is dilated, 



27 

and they terminate in their outer end in a number 
of fringelike processes, the fimbriated extremity, 
that partially surround the ovary. The tubes have 
a serous, muscular, and mucous coat, continuous 
with the similar layers of the uterus. The mucous 
lining is thrown into a number of longitudinal re- 
duplications, and is covered with columnar ciliated 
epithelium. 

The vagina is a musculo-membranous canal lead- 
ing from the vulva to the uterus. Its anterior wall 
is about two and one-half inches long, and the poste- 
rior wall is one inch longer. The walls are in con- 
tact, a transverse section showing the canal to have 
the general shape of the letter H. The axis of the 
vagina corresponds in a general way to that of the 
rectum and the urethra, presenting a slight S curve. 
It is situated between the urethra in front and the 
rectum behind. Its mucous membrane is covered 
with stratified squamous epithelium. 

THE VULVA. 

The vulva comprises those generative organs 
which lie without the pelvis, and are sometimes 
called the " external generative organs." They are 
the mons Veneris, the labia majora, the labia minora, 
the clitoris, and the hymen. 

The mons Veneris is the prominence situated upon 
the symphysis pubis, and is composed of adipose 
tissue covered with integument, upon which abun- 



28 

dant coarse hairs develop after puberty. The 
growth of hair is limited by a straight or slightly 
curved line, and does not extend upward along the 
course of the linea- alba as in the male. The mons 
Veneris is the only portion of the female genitals 
visible when the woman stands erect. 

The labia majora are placed one on either side, 
and are the analogues of the scrotum in the male. 
They are continuous with the mons Veneris above 
and extend nearly to the anus below, w r here they 
become continuous by a thin fold of tissue called the 
" posterior commissure " or " fourchette." The la- 
bia majora have external and internal cutaneous 
surfaces, the external surfaces being covered with 
hair, the internal surfaces of the two labia being in 
contact, but having a cleft between them called the 
" rima pudendi." Between the surfaces of the labia 
are found adipose tissue, blood vessels, and nerves. 
In the lower third are found the vulvo-vaginal, or 
Bartholin's, glands. As the round ligament passes 
through the inguinal canal, it carries with it a pro- 
longation of peritoneum, the canal of Nuck, which 
usually closes, but may remain open and become 
the seat of a labial hydrocele. 

The labia minora are two cutaneous folds richly 
supplied with sebaceous glands. They begin ante- 
riorly at the clitoris, one beginning above and form- 
ing its prepuce, the other beginning below and form- 



29 

ing the frenulum. They pass backward and become 
continuous with the labia majora about their mid- 
dle. They are placed between the deeper portions 
of the labia majora. The labia minora are some- 
times greatly hypertrophied. 

The clitoris is the analogue of the penis in the 
male, and, like it, has two corpora cavernosa, a glans, 
two crura, a prepuce, and a frenulum, but no cor- 
pus spongiosum or urethral canal. It is the seat of 
sexual pleasure, and is richly supplied by the dorsal 
nerve of the clitoris, a branch from the pudic, and 
with sympathetic fibers. 

The hymen is a thin fold of mucous membrane 
placed at the vulvo-vaginal junction. It partially 
closes the vagina, but has an opening in it that va- 
ries very much in shape in different individuals. 
The hymen is usually torn with the first intercourse, 
and is almost destroyed by childbirth, only three or 
four small prominences being left, which are called 
" carunculae myrtiformes." 

The triangular space between the orifice of the 
vagina below, the clitoris above, and the labia ma- 
jora to either side, and into which the orifice of the 
urethra opens, is called the " vestibule." The bulbs 
of the vestibule are two plexuses of veins — one on 
either side of the vestibule and the vaginal orifice, 
just within the vaginal entrance and covered by mu- 
cous membrane. Anteriorly they are connected, 



30 

and posteriorly they extend almost to the posterior 
commissure. 

The fossa navicularis is a space formed by sepa- 
rating the labia majora, and lies between the vaginal 
orifice in front, the fourchette behind, and the labia 
majora laterally. 

NERVE SUPPLY. 

The pelvic organs receive their nerve supply from 
the ovarian and hypogastric plexuses and from the 
second, third, and fourth sacral nerves. 

The ovarian plexus originates from the renal 
plexus, which receives fibers from the smallest 
splanchnic, sometimes also the small splanchnic, 
and the first lumbar ganglion. It also receives a 
branch from the aortic plexus, and, continuing along 
the course of the ovarian artery, is distributed to the 
ovary and furnishes some filaments to the uterus. 

The hypogastric plexus is placed between the 
two common iliac arteries in front of the body of the 
last lumbar vertebra and the promontory of the sa- 
crum. It is devoid of ganglia, and is formed by the 
continuation downward of the aortic plexus and fila- 
ments from the lumbar ganglia. It furnishes a 
branch to the posterior portion of the fundus of the 
uterus, one to the Fallopian tubes ; and then, dividing 
into two parts, it descends by the sides of the rec- 
tum ; and, joining with filaments from the upper one 



31 

or two sacral ganglia, it forms the inferior hypogas- 
tric plexus. Some of the branches of the inferior 
hypogastric plexus go to the viscera direct; while 
others, with the third and fourth, and usually the 
second, sacral nerves, go to form the cervico-uterine 
ganglion, or the " pelvic brain," as denominated by 
Byron Robinson. This is a mass of gray matter 
situated on either side of the junction of the cervix 
and uterus, and through it the sacral spinal nerves 
are chiefly distributed to the pelvic viscera. This 
ganglion supplies the uterus and bladder particu- 
larly, but also branches to the ovaries, tubes, va- 
gina, and rectum. 

According to Riggs, the hypogastric plexus fur- 
nishes vaso-constrictor fibers to the pelvic viscera 
from the aortic plexus and from the lumbar ganglia 
vascero-inhibitory fibers to the uterus. Through it 
pass sensory impulses from the viscera, those from 
the uterus being through the lower dorsal and the 
upper lumbar nerves, especially the second and 
third. 

The sacral nerves supply motor and sensory 
nerves to the bladder and motor and vaso-dilator 
nerves to the vagina. They also supply sensory 
nerves to the os uteri and constrictor fibers to the 
neck of the uterus, which latter Byron Robinson 
believes are to prevent the dilatation of the cervix 
and to act as a guard against uterine rhythm during 
pregnancy. 



32 

The connection of these sympathetic nerves with 
the spinal nerves and the osteopathic centers for 
the pelvic viscera are as follows : 

Uterus. — Sensory second and third lumbar; in 
contraction, tenth, eleventh, and twelfth dorsal and 
first lumbar; os, second, third, and fourth sacral, 
possibly the first also, and rarely the fifth lumbar. 

Vaso-motor first to fifth lumbar, the second lum- 
bar being given as the center for blood supply. 

Ovaries. — The center for these organs may be 
broadly stated to be from the ninth to the twelfth 
dorsal. Quain states that the sensory fibers pass 
through the tenth dorsal ; McConnell gives between 
the tenth and eleventh dorsal as center for the blood 
supply; and Riggs gives the eleventh and twelfth 
dorsal as center for the ovaries. The ovarian 
nerves form connections with the uterine nerves, 
and can be affected througli the lumbar region, 
which is the general vaso-motor center for the in- 
ternal generative organs. 

Vagina. — Motor and vaso-dilator ; second, third, 
and fourth sacral. 

Fallopian Tubes. — Sensory, eleventh and twelfth 
dorsal, and first lumbar. These fibers pass through 
the hypogastric plexus. 

It must be remembered that the hypogastric 
plexus is amenable to direct treatment through the 
anterior abdominal wall, and that the cervico- 



33 

uterine ganglion may be reached per vaginam at the 
cervico-uterine junction. 

The vulva receives its nerve supply from branches 
of the pudic and small sciatic nerves, which are made 
up of filaments from the first to the fourth sacral 
nerve. 



CHAPTER II. 



Examination. 

The examination of a patient, besides being oral 
and physical, as understood by the medical profes- 
sion, is also peculiarly osteopathic. 

The oral examination, or anamnesis, is first in or- 
der, and consists of a number of inquiries pertain- 
ing to the patient's past and present state, as well 
as to conditions which may have had an influence 
in causing any abnormality. 

Present Symptoms. — Naturally the first question is 
to ascertain from what symptoms the patient is now 
suffering. Pain, if present, is usually the most im- 
portant symptom in the estimation of the patient; 
and it frequently enables the physician to locate the 
trouble, though it by no means follows that the dis- 
ease is located where the pain is felt. In diseases 
of the cervix the pain is usually felt over the sacrum, 
while pain due to diseases of the fundus of the ute- 
rus is reflected to the umbilical region. Headache, 



35 

particularly the form in which the pain is felt in the 
top of the head, is often due to uterine trouble, as 
are also pains in the back, down the thighs, and in 
the knees, in which cases the pain is reflected 
through the sacral and lumbar nerves. A sense of 
weight and fullness in the abdomen, the so-called 
" bearing-down pains," is associated with pelvic 
congestion, and frequently with contraction of in- 
flamed pelvic connective tissue. The time of occur- 
rence — whether before, during, or after the period — 
gives some indication as to the location and cause of 
the trouble. Pain of ovarian origin precedes the 
flow for some days ; that due to a diseased endome- 
trium continues throughout the period; while that 
felt just before the flow and relieved by it is usually 
due to a flexion. The pain may be regular or inter- 
mittent, or may be aggravated by certain conditions, 
as standing or walking. 

Duration of Illness. — This will determine whether 
or not the disease is acute or chronic and aids in 
making a prognosis. 

Age. — This is of especial importance in patients 
near the age of puberty or near the menopause or 
in those in whom cancer is suspected. Under other 
conditions the age may be approximated by the pa- 
tient's appearance. 

Social Condition. — Whether or not the patient is 
or has been married or is single has a bearing in a 



36 

great many cases. Many conditions found after 
marriage are rare before that time. 

Number* of Births or Miscarriages. — The incidents 
and accidents of childbirth or miscarriage account 
for a great many conditions. Lacerations of the 
cervix and perineum are almost invariably due to 
these causes ; and many cases of endometritis, men- 
orrhagia,or metrorrhagia can also be traced to them. 
In cases of repeated miscarriages syphilis may be 
suspected. The severity of the labors, whether in- 
strumental or not, and the date of the last, if the 
trouble began after childbirth or miscarriage, should 
be ascertained. If the patient is sterile, it may be 
due to some diseased process. 

Menstrual Habit. — The frequency, regularity, 
amount, duration, and attendant pain of menstrua- 
tion must be known. It must be borne in mind that 
what is customary for one individual is no rule for 
another. Departures from the patient's normal 
habit, the nature of the change, and its time of oc- 
currence are of importance. 

Previous Health. — The past general health, and 
especially that of the pelvic organs, must be inquired 
into. Palpitation or breathlessness may indicate 
anaemia. A neurasthenic condition shows irritation 
to the general nervous system, probably arising 
from the generative organs. 

Previous Treatment, — Operations account for many 



37 

conditions of the perineum, vagina, cervix, uterus, 
and ovaries. This is also true of other forms of 
treatment, as pessaries, caustics, etc. 

Discharge. — The character of the discharge, if 
present, will frequently afford some knowledge of 
the location and kind of trouble. (See " Leucor- 
rhoea. ,, ) Normally the vaginal secretion is not suf- 
ficient to attract attention. It may be thin and 
whitish in color; but when abundant, it may be 
thicker and even creamy in consistence. The cer- 
vical discharge is viscid, clear, and resembles the 
white of an egg. A muco-purulent discharge usu- 
ally indicates gonorrhoeal infection or chronic en- 
dometritis. Watery discharge may come from 
congestion of the pelvic organs, or possibly cancer, 
in which case it will have an offensive odor and con- 
tain more or less blood. Fetid discharges are also 
caused by ulceration, sloughing, retained products 
of conception, etc. Bloody discharges may also be 
caused by endometritis, fibro-myomata, polypi, lac- 
erations, and disease of the cervix. 

Family History. — Deaths of near relatives from 
tuberculosis or cancer or severe neurotic troubles 
may bring light to bear upon the case. 

The patient should now prepare as for an ordinary 
osteopathic treatment by removing the corset and 
dress skirt and putting on a treatment robe or wrap- 
per. The osteopathic examination is now to be 



38 

made. For this it is best to have the patient lying 
on her side on the treatment table. The physician 
stands in front, and by reaching over the patient 
the vertebrae can be readily felt and all irregulari- 
ties and tender points found. No part of the spine 
should be neglected in this examination, but partic- 
ular attention should be given to that part from 
the middle dorsal region down to the coccyx, the 
lower ribs, and to the relations of the pelvic bones 
to each other and to the spine. 

Muscular contractures will frequently be found in 
the lower dorsal and lumbar region; and while they 
affect the sympathetic life to a great degree in these 
situations, such lesions are of even greater etiolog- 
ical importance when found over the sacrum, as they 
often are. This is due to the intimate connection 
between the second, third, and fourth sacral nerves 
and the pelvic organs. In some cases contractures 
will be found to be the chief or only lesions. Mus- 
cular contracture are often secondary to disease 
of the pelvic organs. 

In the dorsal region the condition of the ninth 
to the twelfth vertebra is to be carefully noticed, 
as it is here that lesions affecting the ovaries are 
often found. Lesions above the ninth dorsal may 
also cause pelvic troubles. 

Any single one of the lumbar vertebrae may be 
displaced, or there may be a gradual curve affecting 



39 

the whole region. A posterior curve is most often 
found. The fifth lumbar should be very carefully 
examined owing to its intimate relation to the hypo- 
gastric plexus, which is situated on its anterior sur- 
face, and its location at one of the natural " breaks/' 
or weak places, in the spine. One of the most trou- 
blesome displacements of this vertebra, both as to 
diagnosis and treatment, is an anterior condition. 
Either thin abdominal walls or unusually prominent 
nates may simulate an anterior condition and de- 
ceive the examiner. Tenderness at the sacro-verie- 
bral articulation and the relative position of the fifth 
lumbar to the fourth and to the sacrum will prevent 
a mistake. 

Another lesion that is sometimes found in the 
lumbar region is rotary in character, one of the ver- 
tebrae simply rotating around the tip of its spinous 
process. The spinous process remains in its posi- 
tion relative to the ones above and below it, but the 
transverse process on one side of the vertebra is 
lateral and at the same time posterior, the one on 
the opposite side of the bone being anterior and 
slightly toward the median line. The posterior 
transverse process is very tender, and the muscles 
on that side particularly are contracted. 

Lesions of the lower ribs probably cause trouble 
by impingement upon the nerves leaving the con- 
tiguous intervertebral spaces. Dr ? Still suggests 



40 

that they may cause contraction of the diaphragm, 
and in this way constrict the ascending cava. 

Some of the most important lesions, as well as 
those that will most severely test the diagnostic 
ability of the physician, are those affecting the bones 
of the pelvis. These lesions may involve the pel- 
vis as a whole or any of its component bones. 

The pelvis may be tilted, the crest of the ilium of 
one side being up, while that of the opposite side is 
down ; or it may be slipped forward or backward in 
its relation to the spinal column ; or it may be rotated 
laterally, the anterior superior spine of one side be- 
ing too far forward, w T hile the one on the opposite 
side is too far backward; or it may be tipped for- 
ward or backward, in which case both the poste- 
rior superior spinous processes recede anteriorly or 
are too prominent posteriorly. 

The innominate bones may be displaced down- 
ward and either forward or backward, the latter 
most often, or upward and either forward or back- 
ward, the former most often. Dislocations with a 
downward tendency are more frequently seen than 
those upward. 

In examining for these lesions, some system 
should be followed. The one recommended is to 
begin with the patient on her side facing the physi- 
cian, and then, by reaching over, spinal and rib 
lesions can be detected, as well as tenderness over 



41 

the lumbosacral and sacro-iliac joints and contrac- 
tures and tenderness over the sacrum. Next, have 
the patient turn upon her face, and, with the back 
bare or a very light garment on, the spine and pelvic 
articulations can be further examined. Carefully 
examine the spine by palpation and inspection for 
any abnormality. Notice whether or not the poste- 
rior superior spines are upon the same level in 
regard to the perpendicular of the body, also 
whether or not one or both are too prominent pos- 
teriorly or too far forward. The deviations to be 
expected at this point are upward and downward 
and combinations of these, as upward and forward 
or downward and backward, etc. If both are too 
far forward, the pelvis is tipped forward ; if both 
are too far backward, the pelvis is tipped backward. 
If only one is too far forward, the innominate bone 
of that side is displaced forward and will be found 
to be either upward or downward also. If one is 
too prominent posteriorly, the opposite condition 
obtains. If one is too high and the waist is shorter 
on that side, while the other is low, the pelvis 
is tilted laterally. Tenderness at the sacro-iliac ar- 
ticulation, the crest of the ilium, and at the pubic 
symphysis is said to be pathognomonic of subluxa- 
tion of the innominate. 

The patient is now put upon her back, and after 
carefully relaxing all the thigh muscles by flexion, 



42 

extension, and outward and inward circumduction, 
the length of the limbs is carefully compared. In 
doing this, be sure that the patient is lying straight, 
and that a line passing through the anterior superior 
spinous processes is at right angles to the median 
line of the body. If an innominate be either up or 
down with any of the modifications of these sublux- 
ations, it will show in either a shortened or a length- 
ened limb. 

Examine the symphysis pubis for irregularities. 
A depression, if found, of the upper border of one 
pubic body will indicate the side upon which the 
innominate is anterior. Notice the anterior supe- 
rior spinous processes and the symphysis pubis and 
see if they lie on the same plane. 

The diagnosis may now be verified by having the 
patient sit upon the side of the table and by mak- 
ing the examination in this position. 

Compensatory curves of the spine should also be 
looked for, as they occur as a result of inequalities 
in the length of the limbs. 

PHYSICAL EXAMINATION. 

If the case demands it, the physical examination 
may now be given. No further preparation on the 
part of the patient is required, unless it be necessary 
to inspect the abdomen, when the clothing will have 
to be opened down the front. For this examination 



43 

two positions are almost exclusively used — the dor- 
sal and Sim's, or the left lateral. In the dorsal posi- 
tion the patient lies upon her back, with the knees 
drawn up and separated; in Sim's position the pa- 
tient lies upon her left side, with her left arm be- 
hind her, and at the same time turned so far for- 
ward that the left cheek lies upon a pillow and the 
chest touches the table. The right buttock is turned 
somewhat forward, and is nearer the head than the 
left. The knees are drawn up, the right knee above 
the left and somewhat in front of it. This position 
possesses the advantage of being specially adapted 
to the use of Sim's speculum, in some cases enabling 
the examiner to reach higher in the pelvis, and is 
well suited for rectal examinations and treatment. 

For examining the abdomen the dorsal position is 
used. The methods employed are inspection, pal- 
pation, percussion, auscultation, and occasionally 
mensuration. 

Inspection reveals whether or not the abdomen 
is enlarged, and frequently gives information as to 
the cause of the enlargement. The enlargement 
due to a tumor or pregnancy is more localized and 
accentuated than that caused by the accumulation 
of fat, or fluid in the peritoneal cavity, or gas within 
the intestines. It will disclose any discoloration, 
or linea albicantes, the evidences of previous or pres- 
ent abdominal distention, or other abnormality of 
the surface. 



44 

Palpation first determines the muscular or tissue 
resistance, any localized tenderness, particularly 
over the region of the ovaries, appendix, or hypo- 
gastrium, or the enlargement of any organ or other 
abnormal growth. If a growth of any kind is de- 
tected, its attachment, consistence, size, and degree 
of motion should be ascertained. 

Percussion affords information as to the nature 
of a tumor, whether containing gas or whether it 
is fluid or solid, and also as to its size and distribu- 
tion. If it contains gas, a tympanitic sound is pro- 
duced on percussion ; if it is solid or contains fluid, 
the sound is dull or flat.* The area of tympany or 
dullness should be carefully noted ; and if each 
changes with a change in the patient's position, the 
dull area gravitating to the most dependent part, 
the tympany remaining above, the condition is c : 
with a free fluid in the peritoneal cavity, or ascites. 

Auscultation will determine the existence of preg- 
nancy after the fifth month, if the fetal heart beat 
can be heard. The blowing sound, or uterine 
souffle, caused by the rush of blood through the 
large vessels of a pregnant uterus or a uterine tumor 
can sometimes be heard. 

Mensuration is not often used for abdominal ex- 
amination. It is sometimes useful to determine the 
rapidity of growth of a tumor, two measurements 
being taken at intervals and compared. 



45 

VAGINAL EXAMINATION. 

There is a disposition upon the part of some to 
neglect the intra-vaginal examination, even saying: 
" Many cases of pelvic trouble can be cured with- 
out an examination/' While this may be true, it is 
certainly a fact that any physician attempting to 
cure a pelvic disease without an examination and 
a correct diagnosis is working in a haphazard and 
unscientific manner. It is just as rational to at- 
tempt to cure a general disorder without an osteo- 
pathic examination and as great an injustice to the 
patient. It is only in some unmarried women that 
a vaginal examination must be dispensed with, and 
in these cases much can be learned concerning the 
condition by a rectal examination. 

In this examination it is best to use the index and 
middle fingers of the hand most sensitive to touch. 
In the examination of virgins only the index finger 
can be used, but in all women who have borne chil- 
dren and in most married women two fingers can 
usually be used without great pain or difficulty. By 
the use of two fingers the pelvis can be explored 
nearly an inch higher, stronger and steadier pressure 
can be exerted, and the manipulation of the organs 
is much easier and more thorough. 

The patient occupies the dorsal position. The phy- 
sician stands by the side of the table, his hands hav- 



46 

ing been perfectly cleansed and the fingers anointed 
with vaseline (soap is easier to remove and does 
not stain the patient's clothing, but usually is too 
irritating) ; the unemployed fingers are folded into 
the palm of the hand ; the hand beneath the clothing 
is passed underneath the patient's knee ; the vaginal 
entrance is approached from the side, care being 
taken to keep the fingers well back toward the peri- 
neum. 

The condition of the vaginal walls should be care- 
fully noted; then the cervix must be located and 
examined. The cervix should be about the middle 
of a line connecting the ischial spines, and points 
backward and slightly downward. It will be recog- 
nized as a somewhat cylindrical protuberance into 
the upper portion of the vagina. It feels firm, some- 
what hard, and has a slight depression, the external 
os, in the center of its end. If a laceration has oc- 
curred, the external os will not feel oval or round; 
but the tears radiating from it can be felt, and it 
will seem two-lipped, three-lipped, etc., according 
to the number of tears. The condition of the cervix 
and the external os should be carefully ascertained. 
The position and direction of the cervix is of some 
aid in diagnosing displacements of the uterus, but a 
diagnosis should never be made by the position of 
the cervix alone ; the body of the uterus should also 
be located. Usually if the cervix is anterior to its 



47 

normal position and points downward, there is 
either prolapse or retroversion. If posterior, it has 
been drawn backward by contracting bands of in- 
flamed pelvic connective tissue, and anteflexion is 
probably produced. 

The cervix should next be tested for mobility. 
With a finger on either side — or one finger, if only 
one can be used — it should be pressed toward the 
lateral walls of the pelvis and toward the sacrum. 
If there are any pelvic connective tissue adhesions, 
they will restrict the motion toward the side oppo- 
site the one on which they are placed ; and if they are 
of recent formation, stretching them will cause pain. 
If pain is caused on the side toward which the cer- 
vix is forced, it is caused by pressure upon an in- 
flamed ovary or Fallopian tube. 

The examination of the remaining contents of the 
pelvis is now to be undertaken. This is accom- 
plished by the bimanual method. The external 
hand, which has been resting lightly upon some part 
of the patient's body, is now put upon the abdomen, 
with, at most, only a thin garment between it and 
the skin. The fingers are slightly curved, and a 
gentle vibratory pressure is made in the direction 
of the pelvic axis to one side of the median line 
(about the outer edge of the rectus abdominis) ; and 
at the same time the fingers of the intra-vaginal 
hand feel upward to one side of the cervix until the 



48 

fingers of the two hands are brought into apposition, 
the abdominal wall alone intervening. Having ap- 
proximated the fingers in this manner and ascer- 
tained the thickness of the abdominal wall, the next 
step is to place the intra-vaginal fingers behind the 
cervix; and by moving the external hand and tis- 
sues with it toward the median line, without relax- 
ing the pressure, the uterus is brought between the 
fingers. Its size, tenderness, freedom from growths ; 
its consistence; its position and degree of rigidity 
at the cervico-uterine junction, are all carefully 
noted. 

If the intra-vaginal fingers are now placed in front 
of the cervix and the uterus grasped between the 
fingers of the two hands, the anterior surface of its 
body can be examined. If by the first method of 
examination the cervix was found to be fixed or its 
mobility limited, the cause should now be learned. 
If due to an adhesive band, as is usually the case, 
the band can be examined by pressing the cervix to 
one side so as to make the band tense, while with 
the other finger its size, firmness, and thickness are 
judged. 

The ovaries are best palpated by beginning at the 
angle of the uterus, with the fingers of both hands 
approximated, and examining laterally and posteri- 
orly. It requires considerable practice to locate and 
examine the normal ovary. When enlarged from 



49 

any cause, they are more easily found. When lo- 
cated, their mobility and tenderness should be 
tested. 

The Fallopian tubes, in their normal condition, 
offer still more difficulties for examination. They 
are best examined by beginning at the uterine an- 
gles and palpating outward and backward, as in lo- 
cating an ovary. When filled with fluid or other- 
wise enlarged, they may be recognized by their tor- 
tuous course. 



CHAPTER III. 



Intra-vaginal or Local Treatments. 

The local treatments are of the greatest power for 
good in the relief of pelvic diseases ; and their tech- 
nic, frequency, and contraindications require dis- 
crimination and judgment. 

TECHNIC. 

These treatments are usually given in the dor- 
sal position, frequently in the left lateral, and 
occasionally in the knee-chest position. The 
fingers to be used in the vagina must be rendered 
aseptic by the use of soap and water, and then 
anointed with some unctuous and sterile material, 
as carbolized or plain vaseline. In ordinary treat- 
ments the index finger or index and middle fingers 
of the right hand are used in the vagina ; and with 
the patient in the dorsal position, the physician fac- 
ing her head, with these fingers the right side of the 
pelvis can be more thoroughly treated. Treatment 
of the left side of the pelvis will often be facilitated 



51 

by standing on the patient's left, facing her head, 
and using the fingers of the left hand. 

Counter pressure from above, when necessary, is 
made by the fingers of the hand not employed in 
the vagina. 

No routine treatment can be prescribed, each case 
requiring treatment to meet its individual condi- 
tions. As a rule, there are one or both of two indi- 
cations — to relieve congestion and to correct dis- 
placement. 

Bearing in mind the course of the blood vessels 
between the layers of the broad ligaments, the first 
of these indications is met by getting the tissues of 
the broad ligaments between the fingers of the intra- 
vaginal and external hands and by making gentle 
motions outward and upward, at the same time al- 
lowing the broad ligaments to slip between the fin- 
gers. Another method, easier of application, though 
not quite so effective, is to steady the uterus with 
the external hand and make the motions with the 
intra-vaginal fingers only. 

These directions are applicable only to those cases 
in which the possibility of enlargement of the tubes 
is absolutely excluded. Should there be a suspicion 
of a tubal enlargement, all manipulations must be 
made toward the uterus to prevent the escape of the 
tubal contents into the peritoneum. 

In the vagina the movements may be made from 



52 

the anterior column laterally toward either side. 

Congestion is also relieved by moving the uterus 
in all directions — anteriorly, posteriorly, laterally, 
and upward. This mechanically forces the blood 
from the congested vessels, frees the circulation by 
removing tortuosities, and stimulates nutrition. 

The methods of reducing displacements are de- 
scribed under the treatment of displacements. 

In regard to the amount of force to be used in 
giving local treatment, it is just as easy to prescribe 
the amount of force for every case of inflammatory 
rheumatism. A safe rule is never to cause the pa- 
tient too severe pain. The manipulations should 
be gentle, firm, and deliberate. 

FREQUENCY. 

The vagina is lined with squamous epithelium, 
and is adapted by nature to friction ; while the pel- 
vie organs possess great mobility, and are by nature 
designed to withstand more violence than any other 
of the internal organs. Treatment should, there- 
fore, be repeated as soon as the effect of the previous 
treatment has subsided. This is not oftener than 
every other day, possibly only twice a week ; while 
sometimes, though rarely, a week or ten days should 
elapse before another treatment can and should be 
given. Ordinarily cases do best if treated twice or 
three times per week. 



53 

CONTRAINDICATIONS. 

Acute inflammation of any of the pelvic organs is 
a contraindication to local treatment, and especially 
if the inflammation be purulent. Acute vaginitis, 
endometritis, salpingitis, peritonitis, and cellulitis 
should not receive local treatment until several 
weeks have elapsed since the subsidence of the fe- 
ver, and even then it exceptionally happens that 
the treatment is followed by a slight rise of fever, 
which must be allowed to subside before the treat- 
ment is repeated. 

Menstruation is not a contraindication, but is an 
indication for great care and gentleness. Ordina- 
rily local treatment is suspended during the periods, 
but in some cases of dysmenorrhoea and in stub- 
born cases of displacements caused by adhesions 
more can be accomplished at this time than at any 
other. 

Chronic collections of pus, as before stated, are 
an indication for all manipulations to be made to- 
ward the uterus. 



CHAPTER IV. 



Menstruation. 

Menstruation is the periodical, physiological phe- 
nomena occurring during the reproductive years of 
a woman's life. Its most evident manifestation is 
the discharge through the external generative or- 
gans of a muco-sanguineous fluid. Associated with 
this there is a degeneration and exfoliation of the 
mucous membrane of the uterus and probably of the 
uterine extremities of the Fallopian tubes, conges- 
tion of the tubes and ovaries, a condition of general 
lessened vascular tension, a decrease in the elimina- 
tion of urea, a slight decline in temperature, and an 
unstable condition of the general nervous system. 
All of these conditions go to prove that the system 
is affected throughout. 

The first menstrual period should occur at the 
age of puberty, and marks the development of the 
function of reproduction, although conception can 
take place before the first menstruation. The first 
period should occur between the ages of thirteen and 
seventeen years in warm climates, and is somewhat 
later in cold regions. Occasionally it occurs in in- 



55 

fancy, or it may be delayed beyond the time of phys- 
ical maturity. Menstruation normally ceases at the 
climacteric, or the menopause, between the forty- 
fourth and the fiftieth years. The cessation of men- 
struation between puberty and the menopause, ex- 
cept during pregnancy and lactation, is abnormal. 

Normally, the menstrual periods should occur reg- 
ularly every twenty-seven or twenty-eight days. 
There are many exceptions to this rule, in which 
the interval is habitually a few days longer or 
shorter. The amount of fluid passed is estimated 
to be from four to five ounces, by far the greater 
amount being blood. The average duration is from 
four to five days. Individuals differ very much in 
the length of the intermenstrual period, the dura- 
tion of menstruation, and the amount and character 
of the discharge, each individual having her own 
habit of menstruation, which will be followed by her 
in a normal condition. 

The source of the blood is from the body of the 
uterus and the uterine extremity of the Fallopian 
tube. Preceding the discharge of blood there is a 
thickening of the mucous membrane, due to cell 
proliferation and to congestion of its veins and capil- 
laries. This is followed by cell and plasma infiltra- 
tion beneath the epithelium, which becomes loos- 
ened, undergoes degeneration, and, with the blood 
which oozes from the ruptured capillaries, consti- 



56 

tutes the greater part of the menstrual discharge. 
It is generally believed that only the superficial lay- 
ers of the mucous membrane are thrown off, these 
being re-formed during the intermenstrual period. 

Initiating the period there is a discharge, brown- 
ish or reddish in color, consisting chiefly of vaginal 
mucus, with a small amount of blood. Following 
this there is a discharge of almost pure aiterial 
blood, mixed with vaginal mucus, which prevents 
its coagulation, and with epithelial cells, leucocytes, 
and debris from the uterus. Toward the end of the 
flow the discharge gradually loses its color, dimin- 
ishes, and finally ceases. 

In many cases the inception of menstruation is 
irregular. There may be a muco-serous discharge 
preceding the regular menstrual discharge for a 
month or more, or, following the first menstruation, 
one or several periods may elapse before its reap- 
pearance. This condition is not necessarily patho- 
logical, but a lapse of several periods should demand 
a careful examination as to its cause. 

In those cases in which menstruation is normal 
it is rarely the case that the period is passed with- 
out more or less discomfort, if not some actual suf- 
fering. It is usually accompanied by a feeling of 
malaise, heaviness in the pelvis, headache, digestive 
disturbances, congestion of the tonsils or throat, 
tenderness of the breasts, rings about the eyes, pig- 



57 

mentation of the skin, a peculiar odor to the breath, 
mental depression, or a generally nervous condition. 

THE MENOPAUSE. 

The menopause — the climacteric, or the change 
of life — is the physiological cessation of the menses, 
which marks the end of a woman's fruitfulness. It 
begins from the forty-fifth to the fiftieth years and 
lasts from one year to five years, but, as a rule, is 
completed in two or three years. In rare instances 
the menopause has occurred before the thirtieth 
year, and menstruation has continued into the sixth, 
seventh, and even the eighth, decades of life. It 
occurs late in those in whom menstruation began 
early. 

This condition is the reverse of puberty, being 
the death of a function which has continued on an 
average for thirty-four or thirty-five years ; and 
while it is physiological, it is accompanied by or- 
ganic changes, and is particularly liable to derange- 
ment. Its disturbances are less severe when it 
comes on gradually. 

Pathology. — All of the generative organs undergo 
atrophy. Fat disappears from the vulva, and it be- 
comes flat and wrinkled. The uterus becomes 
smaller, firmer; its mucous membrane is thinned, 
and is often the seat of a catarrhal inflammation. 
The ovaries atrophy, are shriveled and hard, and 



58 

may almost disappear or be converted into fibrous 
tissue. Similar changes occur in the tubes. The 
breasts become flat and shrunken, though some- 
times fat is deposited in them and they enlarge. 

The cervical and hypogastric plexuses are also in- 
volved in this atrophic change, and to their connec- 
tions with the abdominal brain and its branches and 
with the cerebro-spinal nerves are due the numerous 
visceral and mental reflexes that form so distressing 
a feature of the menopause. 

It will be remembered that these changes occur 
often in uteri in which previous disease has left or- 
ganic changes or in those which are the seat of 
active disease. 

Symptoms. — These are legion, though, fortunately, 
all that are enumerated do not occur in every case. 
The first indication of the menopause is derange- 
ment of the normal menstrual habit. An abrupt 
cessation of the menses is very uncommon. The in- 
terval between the periods may be prolonged by a 
few days, a week or more, or one or two periods 
may be skipped, to be followed by a very profuse 
flow at the next period. The flow in other instances 
may continue longer, or sometimes the periods occur 
more frequently. The amount of the flow is usually 
decreased, but the reverse is sometimes true. The 
irregularity increases, the amount of the flow be- 
coming less or the intervals longer, until menstrua- 



59 

tion at last ceases permanently. The more gradu- 
ally the flow ceases, the less will be the general dis- 
turbance. 

During this time numerous other symptoms mani- 
fest themselves. Vaso-motor reflexes will be evi- 
denced by hot flashes or burning sensations, alter- 
nate paleness and redness of the face or other skin 
surfaces. This is often followed by abundant, and 
sometimes fetid, perspiration. The hands and feet 
are continually cold. 

Vertigo, noises in the ears, defective sight, head- 
ache, backache, and neuralgic pains are common. 
The patient is nervous, restless, and irritable ; her 
memory is poor; she is apprehensive, depressed, 
hysterical; and if she has tendencies toward insan- 
ity, it may develop at this time. Areas of hyper- 
esthesia or anesthesia or subjective sensations of 
burning, smarting, or itching may be present. 

Leucorrhoea occurs in nearly half the cases. In- 
digestion and gastric pain, functional disturbances 
of the liver, with jaundice and the appearance of 
hemorrhoids, are common. 

Palpitation of the heart is often a very distressing 
symptom. With it may be faintness and dyspnoea, 
or a sense of fullness in the region of the heart. 

The sexual appetite may be abnormally increased. 
A large number of women gain flesh during the 
menopause. 



60 

Treatment. — Many of these cases prove very trou- 
blesome, for the reason that the avenues of reflex 
disturbances are almost innumerable and on account 
of the restlessness and impatience of the patient. 
One class of symptoms are relieved, only to be fol- 
lowed by others equally distressing. 

Patience, perseverance, and painstaking are the 
price of success, which at times seems marvelous. 

All possible sources of additional irritation should 
be removed. Lesions — not only those affecting the 
pelvic organs, but those of distant organs — should 
be reduced. 

Displacements of the uterus or of the ovaries 
should be corrected and all pelvic adhesions relaxed. 
Endometritis, which is frequently present, must be 
cured. 

Constipation should be relieved at once by ene- 
mata and cured as soon as possible ; the digestive or- 
gans should be stimulated and relieved of all bur- 
dens by a diet which is easily digestible, but nutri- 
tious ; the emunctories should all be kept active. 

All sources of mental disturbance should be re- 
moved and the patient allowed to be as free from 
care and anxiety as possible. 

Gentle, relaxing, general treatment will relieve 
nervousness, insomnia, and assist assimilation. 
Tepid or warm general baths are also useful for this 
purpose. 



61 

Palpitation, gastric pains, or neuralgia receive the 
usual treatment for such conditions. 

Psychic means are sometimes of aid in relieving 
the depression, melancholia, and hysterical tenden- 
cies. 



CHAPTER V. 



Disorders of Menstruation. 

Precocious menstruation is the occurrence of the 
menstrual phenomena every four weeks in a child 
under the age of puberty. While this is a rare con- 
dition, it has been observed from birth, in the first 
year of life, and becomes more common in the suc- 
ceeding years till puberty is reached. In such cases 
the breasts, sexual organs, and sexual appetite are 
usually correspondingly developed. In a number of 
cases menstruation will be found to have begun as 
early as the tenth or twelfth year, this being espe- 
cially the case in warm climates. Such cases may 
be said to be premature rather than precocious. 

The time of the beginning of menstruation is in- 
fluenced greatly by environment, habit, and climate. 
It occurs earlier in those whose nervous equilibrium 
has been disturbed by either poor food, bad hygienic 
or moral surroundings, or from habits of ease and 
indolence or lives of luxury. 



63 

The treatment in these cases resolves itself into a 
search for the cause of the trouble, which is not 
often found. If found, it is, of course, removed. 
It is best not to attempt to arrest the hemorrhage, 
as this may lead to vicarious menstruation. Keep 
the patient quiet at the period, and give general 
osteopathic, dietetic, and hygienic treatment to pre- 
serve the strength of the patient, which suffers un- 
der the loss of blood. The best moral surroundings 
should be preserved. 

Vicarious menstruation is the occurrence at the 

menstrual period of a flow of blood from some part 
of the body other than the uterus or an abnormal 
secretion accompanied by a diminution or a sup- 
pression of the regular flow. 

This condition is also of infrequent occurrence, 
and is seen in debilitated, nervous, or hysterical 
women and in those having a defective innervation 
of the genital organs, causing a scanty menstrual 
discharge. The vicarious hemorrhage has occurred 
from almost all parts of the mucous and skin sur- 
faces, usually from the nose, stomach, lung£, or 
breasts; it has also occurred from lesions on the 
surface, as ulcers or wounds. Of the abnormal se- 
cretions, diarrhoea, leucorrhoea, or a flow of milk 
has been observed. 

The treatment in these cases is clearly indicated 
by the general condition of the patient and the spinal 



64 

or pelvic osteopathic lesions present. The patient's 
general health should be built up by appropriate 
general treatment, the lesions reduced, and the nor- 
mal menstrual flow stimulated, as in amenorrhoea. 

AMENORRHOEA. 

Amenorrhoea is either the failure of the menses 
to appear in a woman who has passed the age of pu- 
berty or the cessation of the flow after it has once 
been established. In the latter case it is called 
t: suppression of the menses." 

Causes. — I. Defective innervation to the internal 
organs of generation from muscular or osseous 
malalignment. Before the age of puberty ample 
opportunity is afforded for the production of various 
lesions which may affect the internal generative 
organs. It is in such cases that the organs reach 
full growth, but their functions are dormant. 

2. Absence or defective development of the uterus 
or ovaries. Such congenital defects are sometimes 
seen in women of otherwise perfect development, 
but are usually associated with faulty development 
of the pelvis or breasts. 

3. Ovarian atrophy. This may result from some 
of the acute febrile diseases — as measles, scarlet fe- 
ver, typhoid fever, etc. — mumps having an especial 
tendency to affect the ovaries by metastasis. Both 
ovaries would have to be destroyed in order to cause 
amenorrhoea. 



65 

4- Atresia of the uterus or vagina, or imperforate 
hymen. 

5. Constitutional diseases acquired before the age 
of puberty, particularly tuberculosis or anaemia. 
In such cases the amenorrhoea is beneficial rather 
than harmful. 

Suppression of the menses may be either tempo- 
rary or permanent. The causes of both forms will 
be considered together. 

1. Osteopathic lesions affecting the nerve or blood 
supply to the internal organs of generation. 

2. Pregnancy and lactation. These are physio- 
logical causes of amenorrhoea, and in every case pre- 
senting itself for treatment the possibility of preg- 
nancy should be eliminated. 

3. Exposure to cold or wetting or chilling any 
part of the body, particularly the feet, during or pre- 
ceding a menstrual period. The feet and pelvic or- 
gans have a very intimate connection through the 
lumbar and sacral nerves. 

4. Obesity. Amenorrhoea and sterility are often 
associated with the rapid accumulation of fat in 
young women. 

5. Systemic diseases; chronic diseases of the 
heart, kidneys, liver, pulmonary tuberculosis, 
anaemia, chlorosis, malaria, and insanity; acute dis- 
eases, as typhoid fever, pneumonia, etc. The per- 
sistent use of morphine may also be considered in 



66 

this connection. The impression prevails among 
the laity that the absence of menstruation is the 
cause of many of these chronic diseases. The op- 
posite of this is really the case. 

6. Overwork and insufficient food; also habits of 
ease, indolence, and luxury. A certain amount of 
exercise is as essential to proper menstrual func- 
tion as overwork and poor food are detrimental to it. 

7. Mental causes. These include a number of 
different conditions. Among them is shock, either 
of a joyous or grievous nature; severe and long- 
continued mental application ; change of climate or 
surroundings ; and fear of conception, either in the 
married or after illicit intercourse. 

8. Removal or disease of both ovaries. In rare 
cases menstruation may continue for a variable 
length of time after the removal of the ovaries, and 
in other cases when their substance seems to be 
completely destroyed. 

9. Removal, atrophy, or disease of the uterus. 
Atrophy of the uterus may follow an operation or 
constitutional or local disease; but most often it 
follows labor or miscarriage, when it is called " su- 
perinvolution. ,, 

10. Pelvic peritonitis. Adhesive bands may con- 
strict the Fallopian tubes, or, by the effect of pres- 
sure direct or upon the blood supply, cause ovarian 
atrophy. 



67 

The gravity of a case of amenorrhoea depends 
upon its cause. In cases of faulty development it 
need excite no alarm, as the patient's health will 
probably not be at all affected by it. Again, in 
cases of severe constitutional diseases the disap- 
pearance of the menses is a conservative process of 
nature, and is for the patient's good rather than 
hurt ; and the function will be reestablished when 
the systemic trouble is relieved and the general 
health is sufficiently robust to spare the blood for 
the flow. In young girls a delay of one period or 
several periods at the beginning of menstruation 
is frequently seen, and no evil consequences follow. 

Symptoms. — Suppression of menstruation, and 
sometimes amenorrhoea, is followed by certain 
symptoms which are most evident about the time 
of the expected flow. These are a sense of fullness 
in the head, rushes of blood to the head, vertigo, 
hot flashes over the body, often heaviness and 
weight in the pelvis, nervousness, hysteria, or hys- 
tero-epilepsy. Should any part of the genital tract 
be occluded, there will be added to these symptoms 
those of a rapidly-growing tumor, which increases 
in size periodically with the onset tff these symp- 
toms. This tumor is, of course, due to the accumu* 
lation of the menstrual flow. 

Treatment. — Emphasis must be put upon the fact 
that amenorrhoea, like the other disorders of men* 



68 

struation, is not a disease per se, but is merely a 
symptom, the cause of which is to be found and re- 
moved. Judgment is to be used in every case to 
determine whether or not it is best to cause the re- 
establishment of the flow, as in some cases already 
mentioned it might prove harmful to the patient. 

The first point to be decided is whether the case 
is one of amenorrhoea proper or suppression of the 
menses. If it be one of amenorrhoea, a thorough 
bimanual examination will determine whether it be 
due to absence or defective development of the pel- 
vic organs or to occlusion of the genital tract or to 
an imperforate hymen. If the ovaries and uterus 
are absent or are in a very rudimentary condition, 
the treatment will be of no avail; if atresia, or im- 
perforate hymen, is found, the treatment must be 
surgical ; if a constitutional disease is the cause, 
the indications are to cure the systemic disorder. 
In some cases in which the organs are well formed, 
but are apparently dormant, good can be done by 
the treatment as given for suppression of the 
menses. 

In menstrual suppression the treatment is also 
adapted to the cause. All osteopathic lesions that 
could directly or reflexly affect the pelvic organs 
should be reduced. In those cases due to cold 
contractures in the lumbar and sacral regions, %nd 
sometimes bony lesions, will be found. In obesity 



69 

the flesh should be reduced by treatment and diet, 
when the menses will in all probability return. 
Good food and rest are to be given to the hungry 
and tired, and exercise, regular habits, and plain, 
but nutritious, food to the indolent and those accus- 
tomed to luxurious habits. In every case attention 
should be given to the respiratory and circulatory 
systems, and their functions rendered perfect if pos- 
sible. 

Lastly come the cases in which it is necessary to 
reestablish the flow. This result is accomplished 
by the removal of all lesions, a thorough relaxing 
and spreading of the lower dorsal and lumbar tis- 
sues. This can be done by straight extension of 
the spine, by " breaking up " the spine, and by the 
" figure of 8 " movement. The lower limbs should 
be thoroughly, but gently, treated out. Circum- 
duction of the foot by holding the ankle with one 
aand and with the other describing circles with 
the patient's toes, several times each way, is said 
to increase the amount of blood in the pelvis. This 
treatment should be continued regularly, and a few 
days before the expected flow the following treat- 
ment may be added to it (in some cases it will be 
necessary to give this treatment continuously with 
that described above) : Lay one hand flat over the 
sacrum, the patient lying on the table on her face, 
and with the closed fist of the other hand strike it 



70 

sharply. A single treatment of this kind has been 
known to cause the appearance of the flow after it 
had been absent for several months. The effect is 
no doubt due to a stimulation of the sacral nerves, 
which tones up the pelvic tissues and organs. In- 
hibition over the lumbar region is also to be given. 
This is the vaso-motor center for the pelvic viscera, 
and its inhibition causes a dilatation of the arte- 
rioles and a more abundant and more vigorous 
supply of blood. As an adjunct to this, hot foot 
baths, hot Sitz baths, and hot applications over the 
epigastrium just preceding the expected flow will 
be of service. If the flow is not established the first 
month, remember that success is the reward of per- 
severance. 

DYSMENORRHOEA. 

Dysmenorrhoea is painful menstruation. As be- 
fore mentioned, it is rare that menstruation is not 
accompanied by some discomfort, if not actual pain. 
Pain is relative, and depends largely upon the sus- 
ceptibility of the individual, the amount of irrita- 
tion which would cause pain in one person being 
scarcely noticed by another. So in dysmenorrhoea 
the patient's temperament or nervous susceptibility 
is to be considered. Owing to this difference of 
sensibility, pain is not always proportionate to the 
lesion causing it. 

Causes. — i. Defective innervation and blood sup- 



71 

ply, due to muscular and osseous lesions to the 
lower dorsal and lumbar regions and in the pelvis. 

2. Uterine displacements. Of these, anteversion 
is the most frequent cause, either when the angle 
produced causes an obstruction to the flow or when 
it interferes with uterine contraction. Extreme re- 
troflexion may cause trouble in the same manner, 
and the remaining displacements by the congestion 
and inflammation which they induce. 

3. Endometritis and pelvic inflammation. In en- 
dometritis the uterine mucosa is in an erethistic 
condition, and the congestion and contractions inci- 
dent to menstruation cause pain. In pelvic inflam- 
mation congestion and adhesions are found. The 
congestion is increased at the period ; and this, with 
the interference with uterine contractions, causes 
pain. 

4. Prolapse of the ovaries and ovaritis. The nat- 
ural monthly congestion increases the weight and 
size of a prolapsed ovary and excites any inflamma- 
tion which may be present. 

5. Exposure to cold and wet. This usually de- 
lays or stops menstruation ; and when the period re- 
turns, it is accompanied by pain. 

6. Narrowing of the cervical canal, either congen- 
ital or acquired. Acquired stenosis is caused by 
the formation of cicatricial tissue or by spasm of the 
cervix. 



72 

7. Polypi of the uterine body or cervix. These 
obstruct the passage of the flow and cause painful 
uterine contractions. 

8. Clotting of discharge. When the flow is scant, 
it forms clots., the discharge of which causes pain. 

9. Neurasthenia. Occasionally there is no cause 
apparent other than a hypersensitive condition of 
the uterine nerves, the menstrual congestion pro- 
ducing pain. In some such cases it is difficult to 
determine whether the nervous condition is the 
cause or the effect of the trouble. 

10. Expulsion of the uterine mucosa entire. This 
is the so-called " membranous dysmenorrhoea/' in 
which the mucosa is exfoliated entire, or nearly so. 
This expelled membrane must not be mistaken for 
the products of conception. 

Symptoms. — The pain may vary from a slight dis- 
comfort to agonizing suffering, which keeps the pa- 
tient in bed through the entire period, and from the 
effects of which she may not recover until the ad- 
vent of the next period, thus rendering her a more 
or less complete invalid. The location of the pain 
varies. It may be located in the lower part of the 
hypogastrium, the pelvis, the iliac fossae, the back, 
or the legs. It may manifest itself as a severe head- 
ache or fixed and continuous pain in some other part 
of the body, accompanying the menstrual period^ 
and not due to some other cause. The location and 



73 

time of occurrence of the pain often indicate the 
seat of the disease. When occurring as much as a 
week before the flow or when felt in the iliac fossae, 
it is ovarian in origin; when occurring a much 
shorter time before the flow, when not relieved by 
it, and when felt in the hypogastric or umbilical 
regions, it is due to disease of the body or fundus. 
When the cervix is involved, the pain is felt in the 
back. If felt during the intermenstrual period, pel- 
vic inflammation may be suspected. 

Treatment. — Dysmenorrhoea is a symptom, and 
not to treat it as such is a mistake. It may be tem- 
porarily relieved without removing its cause, but 
this is by no means a cure. 

All muscular and osseous lesions should be over- 
come ; all displacements of the uterus or prolapse of 
the ovaries should be remedied ; all endometritis, 
oophoritis, or pelvic inflammation must be cured; 
and all conditions that may be disturbing the nerv- 
ous balance must be removed. 

Spasmodic contraction of the cervix is remedia- 
ble by treatment, and cicatricial contraction can 
often be relieved by it; but dilatation or an opera- 
tion may be necessary. Polypi can most readily be 
removed by an operation ; but if the patient will 
not submit to such treatment, good can be accom- 
plished by osteopathic treatment. 

Many cases demand immediate relief. In such 



74 

cases the treatment is inhibition over the sensory 
centers to the uterus at the lower dorsal, upper lum- 
bar, and sacral regions. This not only prevents 
the passage of painful afferent impressions, but also 
the passage of efferent motor impulses, and quiets 
the uterine contractions. The inhibition over the 
second, third, and fourth sacral nerves relaxes the 
cervix and allows the free passage of the flow or 
clots if any are formed. Inhibition of the clitoris 
acts in the same manner, as it is supplied by the 
pudic nerves, whose fibers come, for the most part, 
from the second and third sacral nerves, and possi- 
bly from the first also. 

Those cases due to cicatricial contraction of the 
cervix can often be cured by direct treatment to 
the cervix. It is to be taken between two fingers 
in the vagina and gently, but thoroughly, manipu- 
lated, and any excess of rigidity at the cervico- 
uterine angle reduced. 

Hot applications to the epigastrium and hot Sitz 
baths will prove useful, especially in those cases due 
to scanty menstruation or catching cold. They are 
also valuable in those cases accompanied by a great 
amount of congestion. This is also relieved by 
inhibition of the splanchnics by dilating the abdomi- 
nal blood vessels to accommodate the excess of 
blood in the pelvis. The limbs should be thor- 
oughly treated, flexed, and rotated inward and out- 
ward. 



75 

As a routine practice, raising the ribs and deep- 
breathing exercises should be given, as these are 
perhaps the most powerful agents of diverting the 
blood from the pelvis, relieving congestion, and pro- 
ducing a healthy circulation of the pelvic organs, 
whose circulation is almost as much dependent upon 
the respiratory motions as upon the motions of the 
heart. 

MENORRHAGIA. 

This is an excessive loss of blood at the menstrual 
period. It may be due to an abnormally long contin- 
uance of the flow, or the duration may be normal 
and the flow abnormally abundant. In diagnosing 
this condition the usual amount of discharge, as 
well as the patient's temperament, must be consid- 
ered. A flow which is normal in one individual 
would be excessive in another. Robust and ple- 
thoric women usually menstruate very freely. 

Causes.— These operate by causing or increasing 
pelvic congestion. They are : 

1. Lesions to the lower dorsal, lumbar, and pelvic 
regions. 

2. Uterine diseases. These may be endometritis, 
metritis, subinvolution, laceration of the cervix, 
fibroid tumors (especially the submucous variety), 
polypi, and cancer after the age of thirty-five. 

3. Uterine displacements, particularly retro-dis- 
placements. 



76 

4. Ovarian diseases, either tumors or inflamma- 
tion.- 

5. Pelvic cellulitis or pelvic peritonitis. 

6. Diseases of heart, lungs, or liver. Such dis- 
eases cause general venous congestion, in which 
the pelvic organs participate. 

7. Acute infectious diseases, especially those with 
a hemorrhagic tendency or associated with blood 
dyscrasia — as smallpox, measles, scarlet fever, ty- 
phoid fever, cholera, etc.— and chlorosis, anaemia, 
hemophilia, syphilis. 

8. Obstinate constipation. In rare instances the 
rectum has become so impacted as to cause suffi- 
cient congestion to produce menorrhagia. 

9. Retained portions of placenta or membranes. 
Hemorrhage from this cause is most apt to occur 
soon after the ovum is expelled, but may occur for 
months afterwards. This condition will be sus- 
pected if the trouble begins soon after an abortion 
or natural labor. 

Symptoms. — Besides the appearance of the ex- 
cessive amount of blood, there are weakness, faint- 
ness, prostration, rapid pulse, vertigo ; and if the 
flow continues, there will be all the symptoms of 
anaemia, as pallor, dyspnoea, cold and clammy skin, 
syncope, etc. If not immediately dangerous, the 
repeated loss of blood weakens the patient and re- 
duces her power of resistance against other diseases. 



77 

METRORRHAGIA. 

This is a flow of blood from the uterus independ- 
ent of the menstrual period. The diagnosis is not 
difficult, except in those cases in which the hem- 
orrhages are so frequent and long continued that the 
patient herself cannot tell the normal from the ab- 
normal flow. 

The causes of metrorrhagia include all those of 
menorrhagia, especial attention being called to the 
retention of the products of conception following 
abortion or labor at term in young women and to 
cancer in those who are approaching, passing 
through, or have completed the menopause. All 
cases of metrorrhagia near the climacteric de- 
mand a thorough examination to determine whether 
or not cancer exists. 

Treatment. — Menorrhagia and metrorrhagia are 
symptomatic of so many conditions that the treat- 
ment is quite varied. All osteopathic lesions are 
to be corrected; all uterine displacements and in- 
flammation, as well as inflammation of the ovaries 
and pelvic connective tissue, are to be cured; all 
acute troubles or diseases of the circulatory and re- 
spiratory organs and liver are to be removed and 
constipation relieved. Pelvic congestion must be 
removed by inhibition throughout the lumbar re- 
gion and by expanding the chest and giving deep- 



78 

breathing exercises, as described under the treat- 
ment of dysmenorrhoea. Patients who are anaemic 
from frequent and continued bleeding should be 
given nutritious food, and their digestive and ex- 
cretory functions should be stimulated. 

To stop the hemorrhage and give immediate re- 
lief the treatment is to give a quick and severe jerk 
to the hair covering the mons Veneris. In cases of 
retained placenta or membranes, as first suggested 
by Dr. Bolles, manipulation should be given the 
nipples so as to simulate as nearly as possible the 
sucking of a child, which causes uterine contraction 
and expels the retained structures. If this fails, the 
cervix must be dilated by the finger or an instru- 
ment under anaesthesia and the retained tissues re- 
moved. Stimulation to the lumbar region, particu- 
larly the second, causes a contraction of the blood 
vessels of the uterus. 

An ice bag applied to the hypogastrium or the 
intra- vaginal or the intra-uterine injection of hot 
water is often valuable. 

LEUCOBRHOBA. 

This is an abnormal flow from the vulva or an 
excessive amount of the normal vaginal secretion. 
It is commonly known as the " whites," and is 
symptomatic of some local or constitutional disease. 

Under normal conditions the vaginal secretion is 



79 

just sufficient to keep the parts moist, none of it 
escaping beyond the vulva. It is acid in reaction, 
and contains the vagina-bacillus, which is antago- 
nistic to the development of pyogenic and sapro- 
phytic germs. Any derangement of the normal vag- 
inal secretion predisposes to infection. The source 
of the normal secretion is the vaginal walls, and it 
is formed of desquamated epithelial cells and tran- 
suded blood serum. When excessive under natural 
conditions, white, curdy, or creamy flakes may be 
found in it. The cervical secretion is a thick, tena- 
cious, clear mucus, which usually closes up the 
external os. It is alkaline or neutral in reaction. 

The source of a leucorrhoea may be the vaginal 
walls, the cervix, the uterus, or the Fallopian tube. 

Causes. — I. Pelvic congestion. This may result 
from osteopathic lesions, excessive venery, mastur- 
bation, uterine or ovarian displacements, exposure to 
cold, scanty or suppressed menstruation, pregnancy, 
foreign bodies in the vagina, acute or chronic inflam- 
mation of the pelvic viscera, or malignant disease. 

2. Constitutional conditions — anaemia, tubercular 
diathesis, poor nutrition from insufficient food, men- 
tal or physical overwork, bad hygienic surround- 
ings, and general venous congestion, such as results 
from cardiac or hepatic disease. 

3. Suppression of other secretions. Should the 
flow of milk, the menstrual flow, a diarrhoea, or pro- 



80 

fuse perspiration be suddenly suppressed, leucor- 
rhoea may be caused. 

The abnormal flow may vary in color from the 
clear cervical, or slightly milky vaginal, secretion 
to a yellowish (or greenish) purulent, or reddish 
brown, hemorrhagic discharge. If the discharge 
contains a large proportion of blood, the condition 
becomes a metrorrhagia. 

A clear, thin, serous discharge may be caused by 
a simple congestion of the pelvic organs, the dis- 
charge of a hydro-salpinx, and sometimes by a can- 
cer. A purulent discharge is most frequently due 
to gonorrhoea, though a muco-purulent discharge 
is not infrequent in chronic endometritis. Hem- 
orrhagic discharges are caused by cancer, fibroid 
tumors, and disease of the cervix or endometrium. 
Offensive discharges result from ulceration, slough- 
ing, and retained membranes or placental fragments. 
Cancerous discharges have a peculiar, very offen- 
sive, sickening, and characteristic odor. 

Symptoms. — These are usually a vague feeling of 
weakness and lassitude, to which are added the 
symptoms of the causative condition. If the leucor- 
rhoea is profuse, although it is not hemorrhagic, it 
leads to anaemia. 

Treatment. — Leucorrhoea being symptomatic, the 
treatment resolves itself into the removal of the 
cause ; and as the cause in no two cases is identical, 



81 

the treatment is necessarily different. All osteo- 
pathic lesions must be removed. If there is a local 
organic disease, it must be cured. If simple con- 
gestion of the pelvic organs be the cause, the relief 
of the congestion effects a cure. The congestion is 
relieved by proper local and spinal treatment. If 
the leucorrhoea is the result of some constitutional 
condition, then the treatment is directed to build- 
ing up the general health, and must consist in gen- 
eral osteopathic treatment, combined with dietetic 
and hygienic measures. Hydrotherapy will prove 
a valuable adjunct in these cases. 

Leucorrhoea is relieved by strong inhibition over 
the sacrum and by copious injections of water as 
hot as the hand can bear immersion in for three or 
four minutes. These injections relieve congestion 
and exert an alterative influence upon the uterus. 



CHAPTER VI. 



Diseases of the Vulva. 

MALFORMATIONS. 

Various deformities of the parts comprising the 
vulva are sometimes seen. 

Hypertrophy of the labia, especially the labia 
minora, is occasional, and may be congenital or 
caused by disease or follow the habit of masturba- 
tion. Atrophy of these structures may occur from 
nondevelopment, but after the menopause a certain 
degree of atrophy is natural. 

The clitoris may be h}^pertrophied even to the 
size of a penis. The prepuce of the clitoris may be 
adherent to the glans, forming a hooded clitoris. 
This of itself or as a result of the collection of de- 
composing secretions may give rise to severe nerv- 
ous reflex symptoms, epilepsy having been caused 
by such conditions. 

The hymen may be absent, but is more frequently 
imperforate. This prevents the escape of secre- 



tions and menstrual blood, by which the vagina, and 
sometimes the uterus, is greatly distended. It is 
easily diagnosed by the absence of the orifice of 
the hymen. 

Atresia of the labia may occur, but rarely ever 
gives rise to troublesome symptoms. 

Hermaphrodism is a condition in which an indi- 
vidual possesses both male and female sexual or- 
gans. This is due to congenital malformation, and 
is called " true hermaphrodism " when one or more 
of the organs of each sex are found in the same indi- 
vidual and " false hermaphrodism " when the or- 
gans of only one sex are found, but are so mal- 
formed as to resemble those of either sex. So few 
cases of true hermaphrodism have been found that 
its existence is denied by some. 

In many cases it requires a very close examina- 
tion to determine the sex of the individual. In 
doubtful cases the secondary sexual characteristics 
of voice, development of the breasts, hips, beard, 
Adam's apple, location of pubic hair, and inclina- 
tion toward the opposite sex must be considered. 
Such an individual is called an " hermaphrodite." 

CUTANEOUS AFFECTIONS OF THE VULVA. 

The vulva is liable to certain cutaneous affec- 
tions, which present no unusual characteristics, 
except their location. Of these there are eczema, 



84 

lupus, herpes, and others. As herpes may be mis- 
taken for chancroid, it will be described. 

" Herpes progenitalis," as it is called in this loca- 
tion, begins as one or more small red spots, upon 
which vesicles of similar size soon develop. These 
vesicles are filled with clear serum, and, after their 
rupture, leave a small, shallow ulcer, with abrupt 
edges and a clean base. 

A chancroid becomes a pustule, discharges pus, 
its edges are undermined, and its floor is ragged 
and covered with a dirty, yellowish-green exudate. 

The treatment of herpes is cleanliness and the ap- 
plication of the dusting powder prescribed in vul- 
vitis. 

VULVITIS. 

Inflammation of the vulva is simple, follicular, or 
purulent which in most instances is due to the spe- 
cific poison of gonorrhoea. 

The causes are lack of cleanliness, irritating vagi- 
nal or uterine discharges, dribbling urine, mastur- 
bation, excessive intercourse, injury from nails in 
scratching, worms escaping from the anus and find- 
ing their way into the vulva, and gonorrhoeal infec- 
tion. 

The follicular form is confined to the glands of 
the vulva, while the other forms may attack all the 
vulvar tissues or be localized to any particular part. 



85 

A simple vulvitis may become purulent. Lesions 
affecting the blood or nerve supply are commonly 
present. 

The inflamed parts are hot, swollen, red, and 
painful. Sometimes itching is intense. Hyperse- 
cretion of mucus in the simple form or a discharge 
of muco-pus or pus in the purulent form succeeds 
an initial dryness. Urination is attended by a burn- 
ing pain. Slight fever is seen in severe cases. In 
gonorrhoeal vulvitis infection and inflammation of 
the urethra and the vulvo-vaginal glands are fairly 
constant. Gonococci will be found in the pus in 
these cases. 

Treatment. — Cleanliness is the first essential. The 
parts should be bathed every one or two hours with 
sterile water, or they may be irrigated by using a 
fountain syringe or cleansed by the use of a Sitz 
bath. Wet cloths may be applied at night. In 
gonorrhoeal cases an antiseptic is necessary, and 
for this purpose a two-per-cent solution of nitrate 
of silver is best. 

After cleansing the parts, a protective, antisep- 
tic, and drying powder, formed of equal parts of 
powdered boracic acid and oxide of zinc or talcum 
powder, will hasten the cure. This should be dusted 
on the parts and a small piece of gauze placed be- 
tween the labia to absorb the secretions and pre- 
vent their contact. 



86 

PRURITUS VULVAE. 

This is a condition characterized by intense itch- 
ing of the vulva and frequently of the surrounding 
tissues also. 

Its causes may be direct or reflex. 

The direct causes are irritating discharges from 
the vagina or uterus ; local eruptions ; stiff, broken, 
or deformed hairs on labia; pediculi pubis ; vulvitis ; 
dribbling of urine, especially diabetic urine — all of 
which are aggravated by the congestion accompa- 
nying menstruation or pregnancy. Sedentary hab- 
its, pld age, the menopause, and a low state of health 
are predisposing causes. 

Reflex causes are irritation to the sympathetic or 
cerebro-spinal nerves distributed to these parts. 
The irritation may be from osteopathic lesions or 
due to disease of some of the pelvic organs. 

Symptoms. — These may occur in intermittent at- 
tacks, or there may be a continuous, intolerable 
itching that compels the patient to scratch herself, 
which, in turn, increases the irritation. Sleep is 
often disturbed, the attacks frequently coming on 
after going to bed; the appetite is impaired; the 
mind becomes depressed in severe cases ; the pa- 
tient secludes herself, and may be driven to such 
desperation as to commit suicide. The habit of 
masturbation is sometimes contracted in the efforts 
to relieve the itching. 



87 

Prognosis. — This is sometimes a very intractable 
disease, and may continue for months, or even for 
years. 

Treatment. — The location of the cause and its re- 
moval are first in order. All osteopathic lesions 
should be removed ; all irritating discharges should 
be relieved or prevented from passing over the 
vulva by cleansing douches or a tampon of cotton 
in the vagina. The parts should be kept dry ; fric- 
tion from any cause should be prevented ; applica- 
tions of the drying powder recommended in vul- 
vitis should be made; strong inhibition over the 
sacrum should be made to allay itching. Cold ap- 
plications are also of value for this purpose. 

URETHRAL CARUNCLE. 

This is a small, extremely sensitive and irritable 
vascular tumor, which develops at or near the ure- 
thral meatus. The growths may be single or mul- 
tiple, and vary in size from a growth scarcely dis- 
cernible to a tumor as large as a cherry. 

Urethral caruncles may exist without causing 
symptoms, but usually cause intense pain on urina- 
tion or copulation ; and, occasionally, walking or the 
mere contact of the clothing is very painful. 

Such growths are diagnosed by their location, 
size, great sensitiveness, and red and vascular ap- 
pearance. 



88 
The treatment is removal of the growth. 

VENEREAL WARTS. 

These are small, papillomatous growths found 
upon the external genitals, usually upon the labia 
minora and about the fourchette; but in some in- 
stances they extend up into the vagina, around the 
anus, or onto the thighs. They may be as small as 
a pin head; but if neglected, they may, by aggre- 
gation, grow as large as a walnut. 

They are due to uncleanness, irritating dis- 
charges, and frequently occur with gonorrhoea, 
syphilis, or chancroid. They cause but little or 
no pain, but by their presence may interfere with 
urination, defecation, or coition. When occurring 
on mucous surfaces, they may be mistaken for mu- 
cous patches, but are diagnosed from these by the 
absence of the history or signs of syphilitic infection. 

The treatment is removal. 

CHANCROID. 

This is a local, infectious ulcer transmitted by 
sexual contact and not infrequently found on the 
vulva. When on mucous surfaces, it begins as a 
small, yellow spot, surrounded by a red, inflamma- 
tory areola. The macule becomes a pustule, and 
then an ulcer, with sharply-cut or undermined edges 
and a dirty-yellow, pus-covered base. The stage of 



89 

pustulation may be absent when the chancroid is 
located on the skin. The ulcer has an abundant 
purulent discharge. The inguinal glands enlarge 
and may suppurate. 

Treatment. — The ulcer should be freely cauterized 
with nitric acid and dressed antiseptically. 

CYSTS AND ABSCESS OF THE VULVOVAGINAL GLANDS. 

The ducts of the glands of Bartholin may become 
occluded and an elastic tumor form in the posterior 
part of the labia majora. The cyst may vary in 
size from a cherry to a hen's egg. 

These glands are also subject to inflammation. 
Gonorrhoea is the most frequent cause, and often 
leads to the formation of an abscess. There will be 
the formation of a tumor, as in a cyst; but it will be 
attended by redness, pain, heat, and possibly a 
slight rise of temperature. A drop of pus can usu- 
ally be squeezed out of the gland duct. 

Treatment. — Before the development of pus, cold 
applications and local relaxation of the tissues may 
abort the abscess; After pus has formed it should 
be evacuated. 

LABIAL VARICOCELE. 

Varicosities of the veins of the vulva, especially 
those of the bulbs of the vestibule, are sometimes 
seen as a result of obstruction to the return circula- 
tion from these parts by a pregnant uterus, pelvic 



90 

tumors, fecal impaction, straining efforts, etc. An 
enlargement is produced usually in the labium ma- 
jus, in which the dilated and tortuous veins may be 
easily felt. A dilated condition of the veins of the 
vagina and thighs is often also present. 

The varicocele may cause a sensation of weight 
or burning, and the tumor may sometimes grow as 
large as an orange. Rupture of the veins may oc- 
cur. 

Treatment. — Removal of the obstruction when 
possible, rest in the recumbent posture, relaxation 
of the tissues around the veins, and the local appli- 
cation of cold will result in a cure in most instances. 
If these fail, the veins should be ligated and excised. 

PUDENDAL HYDROCELE AND HERNIA. 

The tubular prolongation of peritoneum around 
the round ligament (the canal of Nuck) sometimes 
fails to grow together and forms a small pouch, in 
which fluid may collect and form a hydrocele, or a 
knuckle of intestine or a portion of omentum may 
prolapse into it and form a labial or pudendal hernia. 

The diagnosis and treatment of this condition are 
similar to that of hydrocele or inguinal hernia in the 
male. 

TUMORS OF THE VULVA. 

The vulva, like other tissues, is subject to benign 
and malignant tumors, which have the same gen- 



91 

eral characteristics of similar growths situated else- 
where. 

INJURIES TO THE VULVA. 

These occur from violence, from falls upon hard 
objects, from parturition, from rape, and occasionally 
from the first intercourse. 

Should the skin be broken, hemorrhage will be 
caused, with soreness, tumefaction, and discolora- 
tion. If the skin remains intact, there will be ex- 
travasation of blood into the tissues, with the other 
symptoms. 

Treatment. — If there is bleeding which cannot be 
controlled by pressure or hot or cold water, the 
bleeding vessels should be ligated. The pain and 
swelling will also be relieved by the applications of 
heat or cold. If the effused blood is not absorbed 
or suppuration should occur, surgical measures to 
remove the clot or open the abscess are in order. 



CHAPTER VII. 



Diseases of the Vagina. 

MALFORMATIONS. 

The vagina may be congenitally absent, partially 
absent, stenosed, or atresic. When congenital, such 
conditions are often associated with defective devel- 
opment of the uterus. 

Stenosis, or atresia, may also result from con- 
traction following sloughing or from adhesions 
forming between the inflamed vaginal walls. Ste- 
nosis may be sufficient to interfere with copulation 
or parturition. Atresia causes retention of the vag- 
inal secretions and of the menstrual flow. 

Occasionally the vagina is double, and is asso- 
ciated with a double uterus in most instances. 

The treatment of these conditions is surgical. 

VAGINITIS. 

Inflammation of the vagina occurs usually in a 
simple or catarrhal, a purulent or gonorrhoea! , and 



93 

a follicular form. Other varieties of inflammation 
are described as granular, adhesive, emphysema- 
tous, etc.; but these are rare, and, when they do 
occur, are secondary stages of the three principal 
varieties. 

Causes. — I. Chronic congestion is the most im- 
portant predisposing cause, and results from osteo- 
pathic lesions, uterine disease or displacement, tu- 
mors, pregnancy, etc. 

2. Irritation from exposure to cold, discharges 
from the uterus or through fistulae from other or- 
gans, excessive intercourse, or masturbation. 

3. Injuries from rape, foreign bodies, caustics, or 
instruments. 

4. Gonorrhoeal infection is the cause of the puru- 
lent or specific form, although a simple vaginitis 
may become purulent, but not specific, without in- 
fection by gonococci. 

5. Too severe or too frequent local treatment may 
cause a mild simple vaginitis. 

Pathology. — The blood vessels are congested; the 
surface is red, swollen, painful, and, during the first 
stages, dry. The dryness is soon followed by an 
increase of secretion, which in severe, simple, and 
always in gonorrhoeal, cases is purulent. 

Follicular vaginitis is usually confined to the fol- 
licles of the upper portion of the vagina. 

Owing to the fact that the vaginal mucous mem- 



94 

brane is very similar to the skin in structure, the 
deeper tissues are protected by the several layers of 
stratified epithelium upon its surface, and the in- 
flammation rarely extends to them. 

Symptoms. — These are constant, burning pain in 
the vagina, frequent and painful urination, pain on 
intercourse, itching and burning about the vulva, 
heaviness and weight within the pelvis, backache, 
an abundant muco-purulent or purulent discharge, 
malaise, anorexia, and slight fever. 

Diagnosis. — The absolute diagnosis of gonorrhoea 
in a woman is almost, if not altogether, impossible, 
unless it is found that she has had intercourse with 
a man suffering from the disease. 

A severe urethritis may be caused in the male by 
the pus from a simple vaginitis; so that it by no 
means follows that urethritis in the male is caused 
by gonorrhoea in the female. 

Prognosis. — A simple vaginitis is not a serious 
trouble; but when gonorrhoeal, it may lead to se- 
rious and fatal consequences by extension through 
the uterus and tubes and the infection of the pelvic 
peritoneum. If the eye should become infected, a 
gonorrhoeal conjunctivitis will be caused, which is 
a very serious matter, so far as sight is concerned. 
Gonorrhoeal rheumatism is also sometimes caused. 

Treatment. — In this trouble cleanliness is para- 
mount. Douches of warm, sterile water or boracic- 



95 

acid solutions should be used in the simple or follic- 
ular cases, but should not be used in the gonor- 
rhoeal cases when it is possible to obtain cleanli- 
ness without them. In gonorrhoeal vaginitis the 
douches often carry the germs up to and into the 
cervix and cause an extension of the disease to the 
cervix and uterus. Cleanliness is procured by the 
use of a Sim's speculum and swabbing out the va- 
gina with absorbent cotton or sterile gauze. In 
these cases an antiseptic is necessary, a two-per- 
cent solution of nitrate of silver being preferable, 
and should be applied to the vaginal mucous mem- 
brane with a small mop of cotton or gauze after the 
cleansing swabbing, which should be given every 
four to six hours during the height of the inflam- 
mation. A small piece of gauze well sprinkled with 
a powder of boracic acid and talcum powder will 
prevent the apposition of the vaginal walls, will 
have an antiseptic effect, and will drain the secre- 
tions from the vagina. 

In the simple cases a continuous current of hot 
water within the vagina is useful. 

Inhibition over the sacrum and gentle treatment 
of the limbs, raising the ribs, and deep-breathing 
exercises should be given to allay the inflammation 
and divert the blood from the vagina. 

In all cases the patient should be kept quiet and 
given light or liquid diet. 



96 

VAGINISMUS. 

This is a painful reflex contraction of one or more 
of the muscles of the vagina. The contraction is 
most often occasioned by attempts at coition, ren- 
dering this act very painful or impossible, or may 
be produced by a digital or instrumental examina- 
tion. _ 

Its causes are vulvitis, vaginitis, excoriations 
about the vulva, urethral caruncles, sensitive re- 
mains of the hymen, piles, pelvic inflammation, awk- 
wardness, or nervousness. 

Irritations to the vaginal nerves from osteopathic 
lesions are frequently present. 

The treatment is the removal of the cause, dilata- 
tion of the vagina, and strong inhibition over the 
sacrum. 

VAGINAL FISTtJLAE. 

Fistulae, or abnormal openings, may occur be- 
tween the vagina and bladder, urethra, ureter, or 
rectum. They are caused by sloughing or tearing 
of the vaginal walls during parturition, or from in- 
strumental injuries, ulceration from foreign bodies, 
cancerous ulceration, and occasionally from oper- 
ations. 

The symptoms are the escape through the vagina 
of the contents of the viscus into which the fistula 



97 

opens. The vaginal opening is sometimes difficult 
of detection. It may be found by injection the or- 
gan into which the fistula opens with a colored 
fluid and by using a speculum watch for its escape 
into the vagina. Milk is the fluid most frequently 
used for this purpose. 
The treatment is surgical. 

PROLAPSE OF THE VAGINAL WALLS. 

Prolapse of the anterior vaginal wall, which also 
involves the bladder, is called " cystocele," and pro- 
lapse of the posterior vaginal wall, which often car- 
ries with it the anterior wall of the rectum, is called 
" rectocele." This is a disease which is extremely 
rare in women who have never borne children ; 
consequently among its causes childbirth stands 
first. Childbirth causes relaxation of the vagina, 
loss of tone, subinvolution or increase of weight, 
relaxation or rupture of the perineum, or loss of 
support — a combination of conditions favorable to 
prolapse. 

Loss of tone and increase of weight are also 
caused by excessive intercourse, uterine displace- 
ment, or disease, especially prolapse, and by osteo- 
pathic lesions involving innervation and circulation 
to the vagina. 

Straining efforts or constipation predispose to 
rectocele ; distention of the bladder, to cystocele. 

Physical Signs. — In the dorsa' position, on inspec- 



98 

tion, the vaginal orifice is found gaping, and within 
it will be seen a rounded swelling, forming its an- 
terior or posterior walls, or both walls may be 
formed of such a swelling. The tumor grows 
larger with bearing-down efforts. 

Symptoms. — There is a bearing-down sensation, 
and often the patient's own diagnosis is " falling 
of the womb." When a cystocele exists, micturi- 
tion is difficult; the bladder is imperfectly emptied 
on urination ; and the retained urine may decompose 
and cause a catarrhal cystitis, with frequent and 
painful urination. Often it will be necessary for 
the patient to press the prolapsed wall back into the 
vagina before the bladder can be emptied. In rec- 
tocele, defecation may be difficult because of the 
anterior pouching of the anterior rectal wall. Con- 
stipation, proctitis, tenesmus, and hemorrhoids are 
common. 

Treatment. — If the perineum is ruptured, it should 
be repaired. The prolapsed walls should be re- 
placed, congestion relieved, and tone restored by 
local treatment and spinal stimulation. The local 
treatment will consist of sweeping movements 
around the vagina for tonic and diverting effect 
and lifting the uterus as high in the pelvis as possi- 
ble, by which the vagina is lengthened and the 
blood forced out of its walls. 

Constipation should at first be relieved by ene- 



99 

mata, and as soon as possible cured by proper treat- 
ment. 

The perineum should be strengthened by adduc- 
tion and abduction of the flexed knees against re- 
sistance and the perineal muscle contraction exer- 
cises. 

INJURIES TO THE VAGINA. 

The vagina is sometimes injured by the first in- 
tercourse, at which time the hymen is usually, 
though by no means always, torn, and may be the 
seat of severe, though very rarely fatal, hemorrhage. 
Tears of the vagina from this cause are not fre- 
quent, but are serious when they do occur. 

Parturition is the most prolific cause of vaginal 

injuries, and may produce tears which extend 
through its walls and into the surrounding connect- 
ive tissue. 

Violence — as from falls, the introduction of for- 
eign bodies, or obsterical forceps — is not infre- 
quent. 

Injuries to the vagina, if the mucous membrane is 
torn, are attended by hemorrhage, pain, swelling, 
difficulty and pain on locomotion, and dyspareunia. 
The hemorrhage may be slight or sufficient to prove 
fatal. 

Treatment. — All bleeding should be controlled by 

hot or cold applications or the ligation of the bleed- 
LofC. 



100 

ing vessels. The wound should then be treated an- 
tiseptically. 

FOREIGN BODIES IN THE VAGINA. 

Almost all conceivable objects small enough to 
enter the vagina have been found here. Pessaries 
of various kinds or sponges or tampons may have 
been placed there by physicians and forgotten, and 
the patient herself may have introduced articles for 
various reasons. 

By their presence they give rise to pelvic pain, 
painful urination, painful coition, and an offensive 
discharge. Ulceration, fistulae, gangrene, and peri- 
tonitis have been caused by them. 

The treatment consists in the removal of the object 
and the relief of the inflammation. When the for- 
eign object has become imbedded in the tissues, its 
removal may be quite difficult. 



CHAPTER VIII. 



Diseases of the Uterus. 

MALFORMATIONS. 

It is a rare occurrence for the uterus to be entirely 
absent. It may be represented by a fibrous cord, 
a small muscular mass, or it may more nearly ap- 
proach the normal and form what is called an " in- 
fantile uterus." 

In these cases there is not only defective devel- 
opment of the remaining sexual organs, with inter- 
ference with ovulation and menstruation, but gen- 
eral development is frequently impaired, and nerv- 
ous and mental disturbances may be present. 

The following malformations are due to more or 
less incomplete coalescence of the Miillerian ducts: 

Uterus unicornis is a condition in which only one- 
half of the uterus develops, the other half being ab- 
sent or rudimentary. 

Uterus bicornis is a condition in which each 
cornu is distinct and separated by a notch externally 



102 

and internally by a partition which may extend as 
low down as the external os. 

Uterus didelphys is the development of two dis- 
tinct uteri, each with a single tube and ovary. The 
vagina is usually double. 

Uterus septus is an apparently normal uterus, 
with a partition dividing its cavity. 

Atresia of the uterus is sometimes seen, and may 
be congenital or acquired as the result of adhesions 
forming after inflammatory aflfections of the cervix 
or body of the uterus. 

Absence, rudimentary development, and atresia 
cause amenorrhoea, which may or may not be ac- 
companied by the symptoms of approaching men- 
struation. An infantile uterus is attended by scanty 
menstruation, often dysmenorrhoea and sterility. 
The other conditions are not recognized, as a rule, 
except on post-mortem examination or in the search 
for the cause of some abnormality of menstruation, 
pregnancy, or parturition. 

Treatment. — In cases of infantile uterus the treat- 
ment is to stimulate all the uterine functions. In 
the other conditions treatment is unnecessary in the 
absence of symptoms ; and when these do arise, the 
treatment is surgical. 

ACUTE ENDOMETRITIS. 

This is an acute inflammation of the mucous 



103 

membrane of the uterus. In every case more or less 
of the muscular tissue of the organ is involved ; and 
under this head will also be considered metritis, or 
inflammation of the uterine walls. 

By some authors this disease is classified into 
cervical and corporeal endometritis, according to 
the location of the inflammation. While it is true 
that the cervix is frequently affected alone, still 
such a classification is an unnecessary refinement 
both in regard to diagnosis and to treatment. 

Causes. — i. Osteopathic lesions are great predis- 
posing causes by interference with innervation and 
blood supply and lowering local vitality. Acting 
in the same manner are displacements or conges- 
tion from any cause. 

2. Exposure to cold, particularly during a men- 
strual period. This causes an interference with a 
natural condition, which easily passes into an active 
inflammation. 

3. Labor or miscarriage, followed by infection by 
pathogenic germs. This is one of the most fre- 
quent causes. The period of involution of itself is 
a predisposition on account of the injuries to the 
uterus and congestion following delivery at term or 
prematurely. 

4. Violence to the mucous membrane of the ute- 
rus from operations, pessaries, or instrumental or 
manual examinations. 



104 

5. Extension of a vaginitis, either simple or spe- 
cific. 

6. Intense sexual excitement, excessive indul- 
gence, or coition during a menstrual period. 

7. Exanthematous diseases are often accompa- 
panied by endometritis. 

A condition of lowered vitality from disease, over- 
work, or poor food predisposes to the disease. 

Pathology. — The mucous membrane in the mild 
cases is congested and somewhat swollen, and the 
epithelium is desquamated. In more severe cases 
the congestion is more intense, the mucous mem- 
brane is red and swollen, and its surface is covered 
with a muco-purulent exudate. The uterus is 
swollen and soft, its blood .vessels are dilated, and 
its tissues are infiltrated with leucocytes and serum. 
Microorganisms are abundant. In severe cases the 
inflammation may extend to the pelvic connective 
tissues or to the peritoneum through the Fallopian 
tubes or by means of the lymphatics. In some 
cases following puerperal infection abscesses have 
formed in the uterine walls. 

Symptoms. — These may vary from a slight sense 
of heaviness and pain in the pelvis, accompanied 
by but little leucorrhoea and the slightest constitu- 
tional disturbance, to very severe and aggravating 
manifestations. There may be pelvic pain and 
heaviness, pain in the back and across the lower 



105 

part of the abdomen, vesical and often rectal tenes- 
mus, and fever from 99 to 101 to as high as 103 to 
104. The abdomen may become tender, tympanitic, 
and vomiting and diarrhoea may be present. A 
thin and serous leucorrhoea appears and in a few 
days becomes thick and purulent or blood stained. 
In gonorrhoeal cases the discharge is purulent, 
thick, and creamy, and may contain blood. The 
discharge is frequently irritating to the parts with 
which it comes in contact. The vagina is often 
tender, hot, and swollen from sympathy, or an ac- 
companying vaginitis. 

On physical examination the uterus is found 
slightly swollen, tender, and a little lower in the 
pelvis than normal. If pelvic cellulitis complicates 
the case, the uterus may be fixed. The cervix is 
swollen, and the external os is slightly patulous. If 
an examination be made with a speculum, the dis- 
charge may be seen escaping from the external os. 

Prognosis. — Mild cases recover in a few weeks, 
but repeated mild attacks may lead to chronic en- 
dometritis. In all cases the possibility of an ex- 
tension and the production of salpingitis, pelvic cel- 
lulitis, or pelvic peritonitis must be considered. In 
some cases of puerperal endometritis a fatal result 
is seen ; but it is owing to the general infection, and 
not to the local inflammation. 

Treatment. — If the case is at all severe, the patient 



106 



must be confined to bed and allowed only light and 
semiliquid diet. Hot applications should be made 
to the hypogastrium and perineum or hot Sitz baths 
should be given. Vaginal injections as hot as can 
be comfortably borne should be given every three 
or four hours during the active stages of the in- 
flammation and warm injections given every six 
hours after this to cleanse the vagina of any dis- 
charge that may accumulate there. Keep the bow- 
els open with daily enemata of warm water. 

The osteopathic treatment consists of inhibition 
over the lower dorsal and lumbar regions to relieve 
congestion and pain. The limbs must also be 
gently relaxed by flexion and circumduction, and 
the muscles must be thoroughly manipulated. 
Deep breathing should be obtained by raising the 
ribs and keeping them up while the patient exhales. 
Appropriate treatment must be given to control any 
fever that may be present. 

No local treatments should be given until the ac- 
tive inflammation has subsided, for fear of an exten- 
sion of the trouble. Intra-uterine injections are pro- 
hibited for the same reason. 

CHRONIC ENDOMETRITIS. 

This, like acute endometritis, may involve the 
cervix or the body alone or both cervix and body. 
It most usually affects the cervix alone, because it 



107 

is more subject to injuries, as in childbirth or coi- 
tion, and to friction whenever there is a prolapsed 
condition of the uterus. Next in frequency the 
whole uterine mucous membrane is affected, and 
most rarely the body alone. 

Pathology. — The mucous membrane is congested, 
dark red in color, soft; and, owing to its swollen 
condition, it may protrude through the external os 
and form a red and inflamed area around it, wliich 
was at one time thought to be ulceration, but which 
constitutes the condition now called " erosion " or 
" granular os." The glands of the cervix are hyper- 
trophied and in a condition of hypersecretion. The 
ducts of the glands often become occluded, and 
small cysts filled with the glairy, viscid, cervical 
secretion are formed. These cysts vary in size from 
a pin head to a pea and often project beyond the 
external os. 

When the body is affected, the mucous mem- 
brane is thickened, soft, and contains many enlarged 
blood vessels, or it may be raised in ridges from the 
cystic and hypertrophied glands, or there may be 
patches of granulations studded over it. Changes 
eventually take place in the walls of the uterus, 
most probably from the congestion consequent upon 
the inflammation. There is a proliferation of con- 
nective tissue between the muscle bundles, causing* 
the uterine walls, including the cervix, to thicken 



108 

and the organ to become enlarged. This condition 
may be confined to the cervix or may affect the 
whole organ. It is known as " chronic paren- 
chymatous metritis " and " areolar hyperplasia " by 
different authors. As a secondary change this 
proliferated connective tissue may contract and the 
uterus be reduced in all its dimensions. 

Causes. — I. Osteopathic lesions by interfering 
with innervation and blood supply cause or allow 
a congested condition of the pelvic organs. The 
congestion of itself, if continued, will cause a 
chronic inflammation, or, more properly, a prolifer- 
ation of connective tissue. Should this change not 
be produced, the congestion is a great predisposing 
condition to more active inflammation. 

2. Constitutional debility from disease, overwork, 
poor food, repeated parturition, or continued lacta- 
tion are important predispositions. 

3. Impeded respiration by tight lacing or sus- 
pending clothing from the waist. Pelvic circula- 
tion is to a large extent dependent upon deep breath- 
ing, and anything that interferes with this is a 
menace to the proper blood supply of the pelvic or- 
gans. 

4. Pelvic inflammation, ovaritis, cellulitis, peri- 
tonitis, and displacements — all these favor chronic 
congestion. 

5. Repeated attacks of acute endometritis. 



109 

6. Injuries to the cervix or uterus, particularly lac- 
erations of the cervix. Other injuries may be from 
premature or normal births, difficult or complicated 
labors, instrumental examinations, pessaries, or at- 
tempts at abortion. 

7. Septic infection following premature labor or 
labor at term. 

8. Subinvolution. This is a frequent cause. 

Symptoms. — These are local, due to the direct ef- 
fect of the inflammation, and are constitutional 
when reflex from the irritation to the abundant sup- 
ply of pelvic sympathetic nerves. 

Leucorrhoea is often the first symptom noticed 
by the patient, and the one which causes her to 
seek relief. If this is from a cervical inflammation, 
the fluid resembles the raw white of an egg; is 
thick, glairy, and tenacious. If it is from inflam- 
mation of the body, it is thin, serous, milky in 
appearance, or, in the most troublesome cases, pu- 
rulent. Again, the discharge may be brownish or 
reddish from admixture with blood. It is some- 
times very irritating to the parts with which it 
comes in contact, and causes almost unbearable 
burning or itching. 

Pain or discomfort is common. There may be a 
sense of heaviness, weight, bearing-down or cramp- 
like pains in the uterus. Pain in the back, loins, 
limbs, and hypogastrium is frequent. The irrita- 



110 

tion may extend to the bladder and cause frequent 
urination, and possibly a severe degree of dysuria. 
Dysmenorrhoea is frequently present just before 
and during the period. 

Menstrual disorders are an important symptom. 
No particular disorder is constant ; for the flow may 
be scant, profuse, irregular, suppressed, or, as is 
often the case, prolonged and painful. 

Sterility is a frequent accompaniment. Not only 
does the inflamed mucous membrane form a poor 
place for the lodgment of the ovum, but the leucor- 
rhoea has a tendency to destroy or dislodge the 
spermatozoa. 

The reflex symptoms are some of the most dis- 
tressing produced by the disease. This is not to be 
wondered at when the extensive sympathetic con- 
nection is remembered. The appetite is lost or ca- 
pricious, and digestive disturbances are present, even 
to nausea and vomiting. Constipation, headache 
(particularly in the occiput), disorders of vision, 
pains in the eyes, irritability of temper, restlessness, 
sleeplessness, melancholia, hysterical manifesta- 
tions, mental and physical fatigue, and breathless- 
ness on exertion may all be found. All of these 
symptoms are not found in every case, but a num- 
ber of them will be present. In some cases the 
mammary glands may become tender, the areolae 
may become more pigmented and extensive; and 



Ill 

these symptoms, in connection with the nausea and 
vomiting and increase in the size of the uterus, may 
lead to a mistaken diagnosis of pregnancy. 

On physical examination the cervix is found to be 
enlarged and tender; the os, somewhat patulous, as 
a rule; and the soft, protruding mucous membrane 
studded with the enlarged and cystic glands (the 
ovula Nabothi) can be felt. If the body is involved, 
the uterus is enlarged and tender on pressure. If 
a speculum be introduced, the os will be found filled 
with a thick, tenacious plug of mucus, or pouring 
from it will be the discharge. 

Diagnosis. — Chronic endometritis must be differ- 
entiated from fibroid tumors and from cancer. The 
first offers but slight difficulty of diagnosis, as a tu- 
mor, if present, will be discovered on careful biman- 
ual examination. Chronic endometritis frequently 
exists with a fibroid. In the latter case the diagnosis 
is sometimes more difficult. Cancer occurs so rarely 
before the age of thirty-five that its existence may 
be almost positively eliminated in a woman who has 
not reached that age. Cancerous tissue is notable 
for its friability and tendency to bleed, and is ac- 
companied by an abundant thin, watery, or purulent 
and very offensive discharge. The early diagnosis 
of cancer is a matter of such importance that, if 
the case can be decided in no other way, a piece of 
the tissue should be clipped from the cervix and 



112 

subjected to a microscopical examination by a com- 
petent pathologist. 

Treatment. — In this as in every other affection 
the treatment should begin by a search for, and a 
removal of, the cause. For this reason a routine 
treatment cannot be given, no two cases presenting 
the same features. 

All osteopathic lesions — osseous or muscular, pri- 
mary or secondary — must be corrected ; and the gen- 
eral health must be restored by appropriate treat- 
ment, diet, and exercise. In all cases corsets should 
be interdicted, the clothing suspended from the 
shoulders, and the abdominal muscles toned up. 
Any tumors or acute or chronic inflammation of the 
pelvic tissues should receive appropriate treatment, 
and all displacements should be corrected. 

Pain and discomfort are relieved by gentle relaxa- 
tion throughout the lower dorsal, lumbar, and sa- 
cral regions, followed by inhibition in the same re- 
gions, particularly from the tenth dorsal to the first 
lumbar and the first four sacral nerves. The irri- 
tation to the bladder is relieved by inhibition over 
the second, third, and fourth sacral nerves. 

The menstrual disorders should receive treatment 
as indicated under their respective heads. 

The reflex constitutional symptoms usually sub- 
side under general treatment, it rarely being neces- 
sary to give specific treatment for the relief of these 
symptoms. 



113 

Besides the local treatment necessary for the cor- 
rection of displacements or relief of inflammation, 
such treatment will prove beneficial in all cases. It 
should consist in bimanually moving the uterus in 
all directions — gently, but thoroughly — and in ma- 
nipulating the organ, both cervix and body, between 
the external and intra-vaginal hands by alternate 
pressure and relaxation gently applied and by cir- 
cular motions executed by the external hand, while 
the intra-vaginal fingers steady the organ and apply 
counter pressure. The effects of these treatments 
must be studied; and if no irritation is excited, the 
treatment may be given as often as three times a 
week. If irritation is caused, it should be allayed 
by spinal inhibition and allowed to subside before 
the treatment is repeated. Keep the patient quiet 
and in a recumbent posture as much as possible. 
Let the diet be light, but nutritious. 

The cystic glands in some cases will require open- 
ing through a speculum, the opening to be done 
with a bistoury or some other sharp-pointed instru- 
ment. The operation should be followed by a co- 
pious douche of hot water. 

Prognosis. — Relief can almost invariably be given, 
but to effect a complete cure in cases in which there 
is an extensive laceration of the cervix an operation 
to repair the laceration will be necessary. It will 
require from two to six months to receive all the 
benefit obtainable from osteopathy. 



114 



LACERATION OF THE CERVIX. 

This is a condition in which the cervix is torn, 
The tear occurs at the external os, and may involve 
the whole thickness of the cervix. It may extend 
up to the cervico-vaginal junction, and sometimes 
extends beyond this to the connective tissue poste- 
rior to the uterus or to the bladder anteriorly. The 
laceration may be only in one direction, unilateral ; 
in two directions, bilateral ; or in three or more 
directions, stellate. Anterior or posterior lacera- 
tions are rare. 

Causes. — I. Rigidity of the cervix. This may re- 
sult from cicatrices, cervical endometritis, deficient 
development, or may be relative from early rupture 
of the membranes and the absence of the dilating 
force of the bag of waters. 

2. Rapid delivery. This may force the child 
through the cervix so rapidly that proper dilation 
cannot occur. 

3. Abortions. These occurring even in the first 
few months of pregnancy, at a time when the cervix 
is unprepared for dilation, are sometimes respon- 
sible for lacerations. 

4. Operations. The use of the forceps, particu- 
larly before the cervix is properly dilated ; artificial 
dilation for purposes of digital examination or cu- 
rettement; and incisions of the cervix for dysmen- 
orrhoea are not uncommon causes. 

Consequences. — Lacerations afford an immediate 



115 

opportunity for infection of the pelvic structures. 
Cellulitis is not infrequent in deep tears. If the 
laceration does not spontaneously unite, the lips 
of the tear separate. The mucous membrane is then 
exposed to injury from coition and friction against 
the vaginal walls. It becomes congested, red, 
and swollen. The swelling causes it to roll out, 
and a larger surface becomes exposed. The cervical 
glands hypertrophy and secrete a glairy mucus. 
Some become obstructed and form small cysts filled 
with this material, resembling the white of an egg. 
Subinvolution, corporeal and general endometritis 
(with their associated conditions and complica- 
tions), eversion of the mucous membrane of the 
cervix, hypertrophy and hypersecretion of its 
glands, and general pelvic congestion are produced. 

By no means all lacerations are followed by these 
conditions. The majority are single or double 
tears, and heal, leaving only a small amount, if any, 
of cicatricial tissue in the wound, which causes no 
trouble. It is only when there are eversion, hyper- 
trophy, and cystic formation of the cervical mucous 
membrane or when there is a large amount of cica- 
tricial tissue in the wound that symptoms arise. 

Symptoms. — These are practically identical with 
the symptoms of chronic endometritis. 

Diagnosis. — On digital examination the cervix is 



116 

found enlarged; and, instead of the transversely 
oval slit, the os is patulous, the tears radiating from 
it; and the hardened and tender tissue in the an- 
gles of the lacerations will be felt. The everted 
mucous membrane is soft; and in it small, hard 
bodies, the gland cysts, will be felt. 

On examination with a speculum, the red, raw- 
looking mucous membrane, studded with small 
cysts, will be seen protruding from the os, which 
is probably filled with a plug of tenacious mucus. 
The radiating lacerations will also appear. In or- 
der to ascertain the original contour of the os it 
may be necessary to fix a tenaculum in each lip of 
the laceration and approximate the separated sur- 
faces. By this the redundance of mucous mem- 
brane can also be appreciated. 

Differential diagnosis is similar to that of chronic 
endometritis. 

Prognosis. — A subsidence of symptoms follows 
osteopathic treatment in most cases. In some of 
long standing and a large amount of enlargement 
of the cervix and eversion of the mucous mem- 
brane an operation is a preferable procedure. 

Treatment. — This is identical with that of chronic 
endometritis, of which lacerations are a frequent 

cause. 



117 

SUBINVOLUTION. 

This is a condition in which the uterus fails to 
return to its normal condition after parturition, but 
remains large, heavy, congested, and with softened 
walls and thickened mucous membrane. As a re- 
sult of increase in weight and loss of tone, the organ 
is low in the pelvis, and is often retro-displaced. 

Its causes are lesions interfering with innervation 
or blood supply, a previous endometritis, endome- 
tritis following delivery, exhaustion from prolonged 
labor, hemorrhage, or some constitutional disease, 
and especially getting up too early after childbirth. 

Symptoms. — These are a feeling of weight and 
heaviness in the pelvis, backache, continuance of the 
lochial discharge, or a profuse leucorrhoea, con- 
tinued weakness, anorexia, and anaemia. 

The condition is recognized when, after the sec- 
ond month after childbirth, these symptoms are 
present, and the uterus is found large, flabby, low, 
and retro-displaced. 

Treatment. — All lesions must be corrected. Gen- 
eral treatment must be given for systemic tonic 
effect; stimulation over the sacrum, to the breasts, 
and local treatment by direct manipulation of the 
organ, for local tonic effect. 

The diet must receive attention, and should be 
light and nutritious. 



118 

SUPERINVOLUTION, OR ATROPHY OF THE UTERUS- 

This condition is natural after the menopause, 
but is often produced prematurely. It may follow 
parturition, and is no doubt often a secondary stage 
of subinvolution ; it may be caused by endometritis, 
operations on the cervix, or the removal of the ova- 
ries or their degeneration by disease. 

The uterus is small ; its cavity may not measure 
more than an inch or an inch and a half in depth. 

Scanty menstruation, dysmenorrhoea, headaches, 
nervousness, slight melancholia, and general debil- 
ity may result. In some cases a premature meno- 
pause is caused. 

Treatment. — This should consist in building up 
the general health, the removal of the cause (if it 
can be found), stimulation of the uterine functions, 
and relief of the symptoms. 



CHAPTER IX. 



Displacements of the Uterus. 

It must be remembered that the uterus possesses 
a greater degree of mobility than any other internal 
organ of the body. Its position is normally changed 
by every respiratory act, descending with inspira- 
tion and ascending with expiration. It is also 
pushed backward by a full bladder, while a full rec- 
tum presses it forward. Every change of posture 
also affects it. (For correct position and amount of 
mobility, see Chapter I.) 

To constitute a displacement the condition must 
be continuous and fixed. Should the uterus become 
fixed in what is called its " normal position," such a 
condition would be pathological. Before diagnos- 
ing a displacement the condition of the bladder and 
rectum should be known, for it is possible for a 
retroversion to disappear after emptying a distended 
bladder and for an anteposition to be cured by 
emptying an impacted rectum. 



120 

Displacements occur in an anterior, a posterior, 
and a downward direction. The anterior and poste- 
rior displacements may at the same time be lateral, 
and an antero-lateral or a postero-lateral displace- 
ment may be produced. Of the anterior, posterior, 
and lateral displacements, flexions and versions are 
described. 

A flexion is a condition in which the uterus is 
bent and the angle existing between the body and 
the cervix is disturbed. This usually occurs at the 
cervico-corporeal junction, but may occur else- 
where. Either as a cause or an effect of the flexion 
there is a diseased condition of the uterine tissue 
at the point of flexure, and a twofold pathological 
condition is thus produced. 

A version is a turning of the uterus as a whole, 
the angle between the cervix and the body not being 
disturbed. 

ANTEFLEXION. 

This is a condition in which the uterine body is 
bent forward on the cervix, which occupies its nor- 
mal position ; or in which the cervix is bent for- 
ward upon the body, which remains in proper place ; 
or in which both body and cervix are bent forward. 
The first of these is called " corporeal anteflexion ; " 
the second, " cervical anteflexion ; " and the last, 
" cervico-corporeal anteflexion." Anteflexion is also 
classified by some into first, second, and third de- 



121 

grees, according to the angle produced. Such 
classification is of but little practical value. 

This is the most frequent form of displacement, 
probably because it is favored by the normal ante- 
flexion, in which position the uterus is kept by ab- 
dominal pressure and the attachment anteriorly of 
the round ligaments. It is more frequently seen in 
virgins and nulliparae than in those who have borne 
children. 

The consistence of normal uterine tissue is such 
that if the organ be flexed it will spontaneously 
return to its original position when the pressure is 
removed. In every case of anteflexion there must 
occur a weakening of tissue at the point of flexure, 
or the normal tissue rigidity must be overcome. 

Causes. — I. Osteopathic lesions to lower spine 
and pelvis. These produce a great predisposition 
to displacements (a) by causing loss of uterine tone 
or relaxation of ligaments, nearly all of which con- 
tain uterine muscular tissue; (b) by causing con- 
traction of the sacro-uterine and round ligaments, 
which are very rich in involuntary muscular fibers ; 
(c) by interfering with vaso-motor nerves, caus- 
ing congestion and hyperplasia, with consequent 
increase in weight. 

2. Endometritis. This is one of the chief agen- 
cies in weakening the tissues, the normal muscular 
and submucous tissue being replaced by hyper- 



122 

trophied glandular and hyperplastic areolar tissue. 
At the same time a corporeal endometritis increases 
the weight of the uterine body, causing it to tip for- 
ward. Acting in the same manner are subinvolu- 
tion and continued congestion. 

3. Inflammatory adhesions. These are usually 
formed of cellular tissue, and sometimes of perito- 
neum. In most cases they are attached to the ute- 
rus at the cervico-corporeal junction and pass back- 
ward toward the sacrum, in which direction their 
point of attachment is drawn. These adhesions are 
one of the most frequent causes of anteflexion. Ad- 
hesions may also be formed anteriorly, which either 
pull the fundus forward or immobilize the cervix 
so that it cannot recede when the fundus is forced 
down upon it from intra-abdominal pressure. 

4. Increased abdominal pressure. This may be 
from tight lacing, muscular efforts, coughing, tu- 
mors, or ascites. 

5. Impacted rectum. This in rare instances may 
push the cervix forward. 

6. Errors in development. These are usually con- 
genital. 

Symptoms. — The most prominent symptoms are 
dysmenorrhoea, sterility, irritable bladder, and re- 
flex nervous disturbances. 

Dysmenorrhoea is thought to be due to obstruc- 
tion to the egress of the menstrual fluid as a result 



123 

of the bend in the cervico-uterine canal. Proper 
attention has not been given to the irritation of the 
cervico-uterine ganglion as a cause of dysmenor- 
rhoea in these cases. 

Sterility is due to the obstruction to the entrance 
of the spermatozoa into the uterine cavity. En- 
dometritis and leucorrhoea are often associated 
with anteflexion, and they doubtless have some- 
thing to do with the cause of sterility. 

Irritability of the bladder is most often expressed 
by frequent urination and tenesmus. This is due to 
the mechanical irritation of the anteflexed fundus 
preventing full distention of the bladder and to re- 
flex irritation, owing to the intimate connection 
between the uterine and vesicular ganglia. 

The nervous disturbances are varied. Among 
them are headache, backache, epigastric pain, dys- 
pepsia, disturbances of vision, etc. 

Leucorrhoea is a frequent symptom, while a pre- 
disposition to abortion and excessive nausea and 
vomiting after conception is engendered. 

Diagnosis. — In no case should a diagnosis be made 
only from the direction in which the cervix is point- 
ing. In most cases it has a normal direction, and 
occasionally it points forward and downward, when 
without a further examination a retroversion would 
be suspected. If one or two fingers be introduced 
into the vagina and counter pressure be made from 



124 

above, while the finger is swept around the vaginal 
vault about the os internum anteriorly, the fundus 
can be felt. Its presence here must be verified by 
a careful bimanual examination to prove its absence 
from its normal position. The angle between the 
body and the cervix is felt to be more acute. Occa- 
sionally in fat women the examination is facilitated 
by placing the patient in Sim's position, when the 
fundus and the decrease of the angle between the 
body and the cervix can be more distinctly felt. 

In cases due to an inflammation of the tissues 
posterior to the uterus the cervix is higher than 
normal and is directed forward; its mobility is im- 
paired; and, on careful bimanual or rectal exami- 
nation, the cicatricial bands can be palpated. 

The presence of a fibroid tumor can usually be 
determined by palpation, but in rare instances the 
diagnosis is made more certain by the use of a sound. 

Treatment. — The first step in the treatment is the 
removal of all osteopathic lesions. Endometritis 
should be treated as indicated elsewhere. All con- 
ditions increasing intra-abdominal pressure should 
be avoided, such as tight lacing, excessive muscular 
efforts, etc. ; all clothing should be suspended from 
the shoulders ; constipation should be overcome ; 
and the general health should be built up. 

The internal or local treatment is of great im- 
portance, for in the majority of cases cicatricial 



125 

bands are responsible for the displacement. These 
are usually attached to the posterior surface of the 
uterus near the point where the peritoneum is re- 
flected from its posterior surface, and pass back- 
ward and outward to the front and sides of the sa- 
crum, either on one side or both sides. Such bands 
must be relaxed. This is best accomplished by 
placing two fingers of the left hand in the posterior 
vaginal vault behind the cervix and then placing the 
finger tips of the right hand behind the uterus from 
above. The fingers of the two hands are to be ap- 
proximated and the uterus pushed forward until 
the patient warns the operator to stop, as the pain 
may be a little severe. While the fingers in the 
vagina press the uterus forward and stretch the 
adhesions, they may be further relaxed by gentle 
circular or transverse manipulations executed by 
the fingers of the external hand. This treatment 
may be repeated as soon as the effects of the pre- 
vious treatment have worn off. If any irritation is 
caused, it can be relieved by inhibition over the 
lower dorsal and lumbar regions, the sensory 
uterine centers. 

By somewhat similar means anterior adhesions 
drawing the fundus forward can be relaxed. The 
process is simply reversed. The internal fingers 
are placed in the anterior vaginal vault and the 
uterus is pressed backward, the external hand as- 
sisting and manipulating as before. 



126 

The uterus may be straightened out by the inter- 
nal fingers pressing the apex of the angle forward, 
while the fundus is pressed backward by the exter- 
nal hand. 

Tone is imparted to all the pelvic structures by 
slight stimulation over the sacrum. This should 
not be given during pregnancy, as there may be 
danger of causing abortion. 

ANTEVERSION. 

This is a condition in w r hich the fundus of the 
uterus is turned forward and downward, while the 
cervix passes upward, there being no change in the 
angle formed between the cervix and the body. 

This is neither so frequent nor so troublesome a 
condition as anteflexion. 

Causes. — I. Osteopathic lesions operating as in 
anteflexion. 

2. Endometritis, congestion, subinvolution, tu- 
mors, pregnancy, etc. All of these conditions in- 
crease the weight of the uterus and cause it to tip 
forward when standing or sitting. 

3. Inflammatory adhesions. These may be in 
the anterior portion of the pelvis and draw the fun- 
dus forward and downward, or they may be along 
the course of the sacro-uterine ligaments and draw 
the cervix upward, the tissues not being diseased 
or the tissue resistance overcome, as in anteflexion. 



127 

4- Increased abdominal pressure, by which the 
fundus is forced downward; tight clothing, muscu- 
lar efforts, ascites, tumors, etc. 

5. Relaxation of the abdominal walls and the con- 
sequent weakening of their sustaining power. 

Pathology. — The uterus is enlarged, congested, 
and in a state of chronic inflammation. Adhesions, 
either anteriorly or posteriorly, may be present, or 
a tube or ovary may be bound forward to the ante- 
rior pelvic wall. From lack of use the sacro-uterine 
and round ligaments are retracted, preventing spon- 
taneous replacement; and as a result of the con- 
stant tension the vesico-uterine ligaments are 
stretched and relaxed. 

Symptoms. — These are to a large extent due to the 
associated chronic endometritis. The symptoms 
are not as pronounced and constant as they are in 
anteflexion. Marked cases of anteversion may per- 
sist for a long time and produce but few and slight, 
if any, symptoms. 

Frequent micturition and irritability of the blad- 
der are caused by the pressure of the anteverted 
fundus upon the bladder. 

Dysmenorrhoea and sterility may be caused by 
the closure of the os from its close apposition to 
the posterior vaginal wall and the chronic endome- 
tritis. In some cases in which the fundus points 
downward and is lower than the cervix it will re- 



128 

quire more powerful uterine contractions to expel 
the flow against the influence of gravity, and this 
may cause pain. 

Metrorrhagia and leucorrhoea are occasional 
symptoms, and are doubtless largely due to the 
associated chronic endometritis and congestion. 

An irritable condition of the rectum, in rare in 
stances amounting to tenesmus, may result from the 
pressure of the cervix against the rectum. 

Diagnosis. — On making a vaginal examination, 
the cervix is reached with difficulty. It is higher 
than normal, is directed backward toward the hol- 
low of the sacrum, and occasionally is directed 
somewhat upward. On passing the finger forward 
to the anterior vaginal vault, the anterior surface 
of the body can be felt passing forward toward the 
symphysis pubis. A careful bimanual examination 
should now be made to confirm this position. 

Treatment. — This is directed toward the removal 
of the cause, the relief of the associated congestion 
and inflammation, and such mechanical means as 
will restore the uterus to its normal position and 
maintain it there. 

The osteopathic lesions are to be removed; the 
endometritis, subinvolution, etc., are to be treated 
as indicated under their respective heads; the in- 
flammatory adhesions or contracted ligaments are 
to be treated, as in anteflexion, according to their 



129 

location; the abdominal muscles are to be toned 
up by direct treatment. 

For relief of dysmenorrhoea, metrorrhagia, and 
leucorrhoea, see the articles on these subjects. Ves- 
ical irritability and rectal irritability are relieved 
by replacing the uterus and inhibition over the sec- 
ond, third, and fourth sacral nerves. 

The replacement of the uterus is effected by the 
bimanual method. Two fingers of one hand are 
passed into the anterior fornix of the vagina, and 
the fundus is pressed upward as far as possible. 
The other hand is now placed upon the abdomen, 
and an attempt is made to approximate the fingers 
of the two hands in front of the fundus, so that it 
may be prevented from returning to its abnormal 
condition and at the same time can be forced far- 
ther backward, while the round ligaments are 
stretched and relaxed. The intra-vaginal fingers 
should now be placed in the posterior vaginal for- 
nix and the cervix pressed downward and forward, 
by which the further replacement of the uterus is 
effected and the sacro-uterine ligaments are relaxed. 

The relaxation of the round ligaments is facili- 
tated by inhibition over their insertion in the mons 
Veneris and at the point at which they cross the 
spine of the pubis. The sacro-uterine ligaments are 
relaxed by inhibition of the sacrum. 

After replacing the uterus, it is best for the pa- 



130 

tient to remain in the dorsal position for an hour 
or more, if possible. 

BACKWARD DISPLACEMENTS. 

Of these there are two — retroversion and retro- 
flexion. They correspond to anteversion and ante- 
flexion, the cervico-corporeal angle being changed 
in the first and unaltered in the second variety. 

Of these displacements, different degrees are arbi- 
trarily given by different writers; but as there is 
no clear distinction between the degrees and as the 
symptoms are not always proportionate to the 
amount of displacement, such a division is of no 
practical importance. 

Causes. — I. Osteopathic lesions. These cause re- 
laxation of uterine tissue and ligaments, and, by 
vaso-motor disturbance, cause congestion, which 
increases the weight of the organ, and, if continued, 
will lead to chronic endometritis. 

In every case of persistent retro-displacement the 
round ligaments are relaxed, and usually the sacro- 
uterine also. This not only allows the fundus to 
slip backward, but also allows the cervix to move 
forward. 

2. Inflammatory adhesions. These may occur 
high up posteriorly, and, by their contraction, draw 
the fundus backward ; or, as is more frequently the 
case, they are situated low down and anteriorly 



131 

along the course of the vesico-uterine ligaments, or 
somewhat laterally in the direction of the obturator 
foramen. These anterior adhesions fix the cervix 
forward, which of itself has a strong tendency to 
force the fundus backward. Distention of the blad- 
der or increased abdominal pressure from a muscu- 
lar effort or some other cause is now only necessary 
to complete the displacement. 

3. Increased weight, particularly of the fundus. 
This may result from pregnancy, subinvolution, 
chronic congestion, tumors, etc. In most of these 
conditions the ligaments participate in the uterine 
changes and become relaxed. 

4. Posture. Following delivery it is common for 
a woman to be placed in the dorsal decubitus ; and, 
in addition to this, an abdominal binder is applied. 
The increased uterine weight and the bandage both 
tend to cause a retro-displacement, and it needs only 
a distended bladder (and sometimes this is not nec- 
essary) to complete it. 

5. Increased abdominal pressure. This may re- 
sult from muscular efforts, tumors, ascites, etc., but 
most often from tight lacing. 

Among less frequent causes may be mentioned 
falls, especially on the buttocks ; constipation, which 
causes straining efforts ; and a fecal mass in the rec- 
tum, forcing the cervix forward. In rare instances 
the fundus is prevented from occupying its usual 



132 

anterior position by the failure of the descent of 
an ovary. 

Pathology. — The uterus is enlarged, slightly pro- 
lapsed, and the endometrium is in a state of chronic 
inflammation. Adhesions are common, as they are 
among the most frequent causes of the condition. 
The ovaries and tubes may be in a state of inflam- 
mation. All of the pelvic organs are congested. 

Symptoms. — If not among the causative condi- 
tions, as a result of the displacement, congestion su- 
pervenes and is accompanied by leucorrhoea, menor- 
rhagia, metrorrhagia, or, if continued for a suffi- 
cient length of time, by chronic endometritis, which 
plays a prominent part in causing sterility and dys- 
menorrhea. 

Constipation is frequent, and in many cases is 
caused by the pressure of the fundus upon the rec- 
tum. For the same reason defecation may be diffi- 
cult, and there is a feeling of fullness in the rectum- 
A sense of weight and heaviness in the pelvis is 
common. Headaches, backache, a pain across the 
sacrum, pain and weakness in the limbs from pres- 
sure on the sacral nerves, and impaired locomotion 
may be present. Abortion is very likely to follow 
impregnation, and dyspareunia and dysuria are fre- 
quent. 

Besides these, the usual reflexes of uterine dis- 
placements are present. The general nutrition suf- 
fers. 



133 

Diagjiosis. — On passing the index finger into the 
vagina, the cervix may be found in its normal posi- 
tion, if the case is one of retroflexion; but more 
frequently it is somewhat anterior, and is directed 
downward, occasionally forward, and in extreme 
cases of retroversion may be directed upward, in 
which case it is hard to reach. 

If the finger is now passed to the posterior sur- 
face of the cervix and upward, the fundus will be 
felt as a hard, round tumor continuous with it. In 
some cases this tumor will be found below the level 
of the cervix in Douglas' cul-de-sac. A tumor in 
this position may be caused by other conditions, 
and it is now necessary to demonstrate the absence 
of the fundus in its normal position. This may be 
done by the bimanual method, which has already 
been described. The diagnosis will be made more 
certain by a rectal examination, when the fundus 
will be felt through the anterior rectal wall. This 
is especially the case in fleshy patients. 

A fibroid tumor, a prolapsed ovary, a hematocele, 
or an ectopic gestation may also produce a tumor 
in the same position in which the retro-displaced 
fundus is found. A careful bimanual examination, 
a thorough study of the history and symptoms of 
the case will in nearly every instance clear up the 
diagnosis. It tliay be necessary occasionally to use 
a sound to show the direction of the uterine canal. 



134 

Treatment. — Preliminary to the replacement of 
the uterus, all the causes of the displacement should 
be removed ; osseous or muscular lesions must be 
reduced ; all adhesions must be relaxed ; congestion, 
chronic endometritis, or increased abdominal pres- 
sure must be relieved ; and the round and sacro- 
uterine ligaments must be toned up b}^ stimulation 
over the sacrum and over the insertion of the round 
ligament into the mons Veneris. 

Replacement may be accomplished in several 
ways, no one of which will prove successful in every 
patient. 

Success usually attends the following: Place the 
patient in the dorsal position. If the patient is mar- 
ried, pass the index and middle fingers — if unmar- 
ried, only the index finger — into the posterior vagi- 
nal vault and press the fundus as far upward and 
forward as possible. At the same time an attempt 
is made to get the fingers of the other hand behind 
the fundus from above by gentle, but firm, pressure 
upon the abdomen. In doing this, place the hand 
upon the abdomen, press the superficial tissues up- 
ward, so that they may be carried with the hand, 
and it will not be necessary to move the hand over 
the skin; then by downward and backward vibra- 
tory pressure penetrate the pelvis. As soon as this 
is accomplished the intra-vaginal fingers are placed 
anterior to the cervix, and it is pushed upward and 



135 

backward, while the fundus is pulled forward by 
the abdominal hand. 

Particularly in virgins, as well as in some other 
cases, it will be found best to pass the index finger — 
and, when it can be borne, to pass both the index 
and middle fingers — into the rectum, and in this 
way press the fundus upward. 

In other cases good results will be obtained by- 
passing two fingers into the anterior vaginal vault 
and making downward and backward pressure at 
the cervico-corporeal junction, and thus straighten 
out the retroflexion angle, if the case be one of retro- 
flexion. Next, the uterus should be pressed up- 
ward and somewhat in the direction of the sacro- 
iliac articulation, and the fundus reached and pulled 
forward by the other hand placed upon the abdo- 
men, as in the method just described. 

Another method sometimes successful is to place 
the patient in Sim's position, the physician stand- 
ing behind her. Two fingers of the right hand, 
palmar surface backward, are passed into the poste- 
rior vaginal vault; the fundus is pushed up, and 
while it is held in this position by the middle finger, 
the index finger is passed to the anterior surface 
of the cervix, which is pressed backward and up- 
ward. This manipulation is now assisted by the 
middle finger also. 

Much can sometimes be accomplished by placing 
the patient in the knee-chest position and forcing 



136 

the fundus forward and upward by the finger in 
either the vagina or the rectum. The same manip- 
ulation described as given in the Sim's position may 
be given in this one. 

Whenever practicable after replacement the pa- 
tient should assume the knee-chest position for sev- 
eral minutes, and then lie down in a position some- 
what similar to Sim's, so that gravity will tend to 
prevent the uterus from returning to its malposition. 
Instruct the patient to assume the knee-chest posi- 
tion for several minutes before retiring at night. 

PROLAPSE OF THE UTERUS. 

This is ordinarily called " falling of the womb," 
and is a condition in which there is a descent of the 
uterus, varying in degree from the slightest descent 
to that state in which it is without the pelvis and 
hangs between the thighs of the patient. In the 
majority of cases the cervix approaches the vaginal 
orifice or protrudes slightly beyond the vulva. 

Different degrees of descent are recognized, as 
first, second, and third. It is also called " incom- 
plete " when the uterus remains in the vagina and 
u complete " or " procidentia " when it hangs with- 
out the vagina. 

Under normal conditions the uterus is retained 
in position by several agencies, no one of which is 
alone of sufficient power to support the organ, al- 



137 

though the loss of one impairs the integrity of all. 
These are the utero-sacral and the utero-vesical lig- 
aments, the connective tissue surrounding the 
uterus and binding it to other organs, the retentive 
power of the abdomen, and the pelvic floor. Of the 
tissues of the pelvic floor, the levator ani is of espe- 
cial importance, owing to the position of the uterus 
relative to the opening in this muscle through which 
the vagina passes. The cervix overlaps the opening 
in the direction of the sacrum and the fundus in the 
direction of the symphysis pubis, so that the uterus 
is transversely placed over it; and to allow pro- 
lapse the cervix must either be brought forward or 
the opening enlarged until the tip of the cervix will 
slip into it. Complete prolapse is restrained by the 
round and broad ligaments. 

Causes. — I. Osteopathic lesions. These interfere 
with the innervation of the ligaments and the pelvic 
floor and cause their relaxation, and, by vaso-motor 
disturbance, cause congestion and increased weight 
of the uterus. It will be seen that they have a two- 
fold influence in causing prolapse. 

2. Childbirth. This is one of the most important 
causes of prolapse. Following it is subinvolution, 
which, as a rule, not only affects the uterus and 
leaves it larger and heavier, but also affects the lig- 
aments and the pelvic floor, as well as impairs the 
retaining power of the abdomen by relaxing and 



138 

weakening the abdominal muscles. Perineal lacer- 
ations are also produced ; and when these involve 
the levator ani, they are a frequent cause. Even 
when the laceration is not so excessive, it may allow 
the formation of a cystocele, which, in turn, draws 
the cervix forward and downward. Lacerations of 
the cervix, with their consequences, tend to cause 
prolapse. If childbirth occurs repeatedly, it acts 
proportionately as a cause of prolapse. 

3. Increased abdominal pressure. This may be 
from tight clothing, continued coughing, efforts at 
stool, violent and continued muscular efforts, falls, 
abdominal tumors, or ascites. A sudden increase 
of abdominal pressure may produce acute prolapse 
in virgins. 

4. Increased uterine weight, tumors, subinvolu- 
tion, chronic endometritis, chronic congestion. 

5. General debility or senile changes. In cases 
of constitutional weakness the uterine supports par- 
ticipate. After the menopause there is an atrophy 
of pelvic tissues and absorption of fat, by which the 
supports are weakened. 

6. Anterior tension on the cervix. This may be 
caused by anterior adhesions, by which the cervix is 
drawn forward into the vaginal opening of the leva- 
tor ani, and abdominal pressure then forces the 
uterus downward. A cystocele or a rectocele has 
the same effect, 



139 

Pathology. — The uterine ligaments are stretched, 
and the vaginal walls are congested, thickened, and 
inverted in proportion to the descent. In cases of 
complete prolapse they may be turned inside out. 
As a consequence of their congestion and increase 
in weight, they make additional tension upon the 
uterus and draw it farther downward. Congestion 
of all the pelvic viscera results from the distortion 
of and obstruction to the blood vessels. 

The cervix, especially if it extend beyond the 
vulva, is eroded and ulcerated — if not from a pri- 
mary laceration, then from the friction against the 
clothing. All of the exposed mucous membrane 
upon the cervix is lusterless, dry, and has rather 
the appearance of epidermis than that of mucous 
membrane. Endometritis, if not originally present, 
results from the congestion. Cystocele and recto- 
cele are constant accompaniments. 

Prolapsus resulting in an obstruction to the 
ureters is the only displacement which has been 
known to cause death. 

Symptoms. — Decided prolapse sometimes exists 
without producing symptoms. Usually a large 
number or nearly all of the following are present: 
Bearing-down sensations ; weight and heaviness in 
the pelvis; a feeling as if all the organs were going 
to drop out through the vagina; irritability of the 
bladder ; frequent, and sometimes painful, micturi- 



140 

tion; inability to void urine until a cystocele is 
replaced through the vagina and the urethra 
straightened out ; difficulty of defecation, if recto- 
cele is pronounced, as feces have a tendency to col- 
lect in the pouch formed by the anterior rectal wall ; 
pain in the back and loins; difficulty in walking; 
discomfort in standing on feet or making slight 
muscular exertions. 

Leucorrhoea is usually present, but menstrual 
derangements are not very common. 

In cases of acute prolapse there is a sensation of 
something having given way, shock, nausea or 
vomiting, rapid and feeble pulse, and clammy per- 
spiration. 

Diagnosis. — On vaginal examination, according 
to the degree of prolapse, the cervix will be found 
forward and low down, resting upon the pelvic 
floor or just within the vaginal orifice or protrud- 
ing from the vagina. In cases of complete prolapse 
the entire uterus may be felt and seen protruding 
from the vulva. In examining for prolapse it is 
often necessary to examine the patient in the up- 
right position, as in this position the maximum of 
prolapse will be evident. 

As a condition very similar to prolapse is caused 
by hypertrophy and elongation of the cervix, to 
verify the diagnosis it is necessary to locate the 
body of the uterus by a bimanual examination. If 



141 

the body is found in its natural position, the case is 
one of hypertrophy of the cervix. Cervical hyper- 
trophy and prolapse may appear together, but in 
cervical hypertrophy the unusual length of the cer- 
vix will be discovered. It will also be an impossi- 
bility to replace the apparently prolapsed organ, 
and an examination by a sound will demonstrate 
the increased depth of the uterus. 

A polypus or an inverted uterus may occasion 
some difficulty in diagnosis, but in neither of these 
conditions is there an opening in the lower end of 
the tumor, while their small ends are upward, the 
reverse of a prolapsed uterus. 

Treatment. — Several of the causes of this condi- 
tion act in conjunction, and all that can possibly 
have any bearing upon it should be found and re- 
moved. 

Replacement is usually not difficult, and is best 
performed in the knee-chest position. In cases of 
complete prolapse, empty the bladder and rectum 
and have the patient assume this position for from 
fifteen to twenty minutes before replacement is at- 
tempted. This allows the intestines to gravitate 
away from the pelvis, and thus congestion is some- 
what relieved. The cervix is now pressed firmly, 
but gently, in the direction of the inferior strait of 
the pelvis. The pressure must be steady, not too 
hurried; and fifteen or twenty minutes should be 



142 

employed in reducing the displacement. Less time 
is necessary in minor degrees of displacement, but 
the procedure is the same. After replacement, a 
sweeping movement, beginning in the anterior wall 
of the vagina and made laterally on each side, 
should be given. This depletes the congested vagi- 
nal walls as well as the tissues between the layers 
of the broad ligament. The patient should be in- 
structed to assume the knee-chest position several 
minutes before retiring every night. 

In no pelvic troubles will deep-breathing exer- 
cises and expansion of the chest be more beneficial 
than in this. Place the patient upon a stool, stand 
behind her, and take one of her elbows in each hand. 
Place the knee high up between the shoulders and 
instruct the patient to take a deep inspiration. As 
she inhales, draw the elbows upward and back- 
ward, and hold them there until the patient exhales. 

Abduction and adduction of the flexed knees 
against resistance is also a valuable movement. It 
depletes the pelvic blood vessels and, through the 
nerves controlling the thigh muscles, has a tonic 
effect upon the pelvic viscera. 

The patient should also be instructed to use a re- 
straining exercise. This is a most important ad- 
junct to the treatment. Instruct her to assume the 
dorsal position, with hips elevated by placing a 
pillow under them; and then contract the perineal 



143 

muscles, as though restraining a movement of the 
bowels. This exercise may be taken just before 
retiring, beginning with from five to ten times and 
gradually increasing to from twenty to thirty times. 

The movement given by some osteopaths for the 
purpose of stretching the broad ligaments is also 
useful. The patient occupies the dorsal position, 
the knees flexed and abdominal muscles relaxed; 
the physician stands at her side, facing her feet, and 
places both hands upon the abdomen low down, 
the finger tips directed toward the median line and 
the ulnar border of the hand parallel to Poupart's 
ligament; the fingers are now pressed as deeply as 
possible into the pelvis, and all the tissues are drawn 
upward and outward. This movement may be re- 
peated several times at each treatment. 

Stimulation over the sacrum has not only a tonic 
effect upon the pelvic tissues, but also upon the 
tissues of the pelvic floor. 



CHAPTER X. 



Neoplasms of the Uterus. 

FIBROID TUMORS. 

Histologically these tumors are composed of the 
same constituents as the uterus — unstriped muscular 
fibers and fibrous connective tissue, with some fusi- 
form cells ; they are, therefore, more correctly called 
" fibro-myomata." They constitute one of the most 
common uterine disorders, it being estimated that 
twenty per cent of all women over thirty-five years 
of age are affected by them. 

In the majority of cases fibroids develop in the 
body of the uterus, occasionally in the cervix. The 
tumor may be single, in which case it is small, or 
it may be multiple and formed of a nest of small 
tumors separated from each other by connective 
tissue septa. The whole tumor is usually sur- 
rounded by a capsule of connective tissue, but in 
some cases the tumor is directly continuous with 
the uterine tissue. Fibroids vary in size from a 
144 



145 

pea to a tumor weighing several pounds, one weigh- 
ing one hundred and ninety-five pounds having been 
reported. 

Fibroids are irregularly globular in form, and, 
when multiple, are distinctly nodular. In con- 
sistence the typical fibroid is hard, gristly, and cuts 
with difficulty, but is softer if the muscular tissue 
predominates or if it has undergone some of the 
many changes to which it is liable. They are non- 
malignant, but are sometimes, associated with ma- 
lignant disease and in rare instances themselves 
undergo malignant degeneration. 

According to their location — just beneath the 
mucous membrane, in the uterine walls, or just be- 
neath the peritoneum — they are classified into sub- 
mucous, interstitial, and subserous fibroids. From 
the uterine contractions resulting from the irritation 
of an interstitial fibroid it has a tendency to become 
one of the other varieties. Fibroids may be either 
pedunculated or sessile — the former, when they are 
attached by a long neck, or pedicle ; the latter, when 
their attachment is by a broad base. If a submu- 
cous fibroid is pedunculated, a polypus is formed. 

While adhesions are not so common as in ovarian 
tumors, nevertheless when they do form they are 
strong and very vascular. A pedunculated, sub- 
serous tumor sometimes becomes entirely separated 
from the uterus and obtains its nourishment from 



146 

adjacent organs to which it has become attached 
by adhesions. 

Fibroid tumors participate in the changes occur- 
ring in the uterus. During a menstrual period they 
become more vascular, larger, and more sensitive. 
They grow during pregnancy, and sometimes dis- 
appear as a result of the involution following this 
condition. After the cessation of ovarian and 
uterine activity following the menopause, they fre- 
quently cease to grow and may atrophy or undergo 
a benign degeneration. 

At any time during their existence they are liable 
to degenerative processes. From constriction or 
torsion of its pedicle a fibroid may become edema- 
tous, or inflammatory changes or sloughing may 
occur. Cystic degeneration, with the formation of 
small cysts in the walls of the tumor, which may 
coalesce and form one large cyst, is sometimes seen. 
The cysts may be filled with a clear, serous fluid 
or bloody or purulent material. Inflammatory 
changes, with pus infection or gangrene — or cal- 
careous, fatty, or myxomatous changes — are seen. 

Endometritis is common. Salpingitis, with a 
bloody or purulent matter in the tubes, is frequent. 
The ovaries are congested and enlarged. If the 
tumor is very large, hypertrophy of the heart may 
result from the obstruction to the circulation. 

Causes. — I. Osteopathic lesions. Clearly the di- 



147 

rect cause of the disease is perverted nutrition, and 
this is induced by irritation to vaso-motor nerves 
that results from lesions. 

2. Nulliparity. Fibroids are most frequent in 
those women who have never borne children. The 
continuous congestion of menstruation is never 
stopped by pregnancy, and, in consequence, the 
hypernutrition resulting from it causes an abnor- 
mal and irregular growth of uterine tissue. 

3. Age. Fibroids occur during the time of sex- 
ual activity, usually from thirty to forty-five 
years of age. Cases have been reported soon after 
puberty, but in such the diagnosis may have been 
wrong. 

Symptoms. — These vary somewhat with the va- 
riety of the tumor, though certain symptoms are 
common to all forms. 

Pain. — This is a rather complex symptom, and 
is produced in various ways. A small interstitial 
or submucous tumor will cause uterine contractions 
and produce more pain than a much larger sub- 
serous one. In these cases the pain is usually 
colicky and paroxysmal. A constant pain is caused 
by distention of the uterine walls, associated peri- 
tonitis, distention of the abdomen, weight of the 
tumor, or pressure upon the sacral nerves causing 
a neuralgic pain in the pelvis and down the legs. 
The severity of the pain is no indication of the size 



148 

of the tumor, as a small tumor within the uterus or 
its walls causes more pain than a larger subserous 
tumor, and a small tumor producing pressure in the 
pelvis causes more pain than a larger tumor which 
rises into the abdomen. Pain is more severe dur- 
ing hemorrhages or menstruation. 

Hemorrhage. — Menorrhagia may be the first in- 
dication of disease, especially in the submucous or 
interstitial variety. The subserous form may at- 
tain considerable size without causing menstrual 
disturbance. Metrorrhagia soon follows. The 
bleeding is very irregular. The patient may be free 
from it for a long time, when it will return in an 
alarming amount. Again, the hemorrhage may be 
slight, but continuous. 

Leucorrhoea is common and alternates with the 
hemorrhages. A profuse watery discharge — hy- 
drorrhoea — is frequently present. 

Pressure symptoms follow enlargement of the 
tumor. From pressure upon the bladder or urethra, 
frequent, difficult, or painful micturition may result. 
Hydronephrosis, pyelitis, or nephritis may be caused 
by obstruction of the ureters ; difficult defecation, 
constipation, or fecal impaction may be produced 
by pressure on the rectum ; edema of the legs, or 
ascites, may result from obstruction to the return 
circulation. The uterus is often greatly displaced. 
It may be prolapsed by the weight of the tumor; 



149 

and if a polypus is attached near the fundus, inver- 
sion may result. 

General Symptoms. — As a result of the continued 
hemorrhages the patient becomes anemic, weak, 
easily exhausted ; and if the tumor is large and 
makes pressure upon the gastro-intestinal tract, di- 
gestive disturbances result. A slight rise of fever 
is occasionally seen, which is often, but not always. 
the result of some suppurative or degenerative 
change in the tumor. 

Diagnosis. — This is made by differentiation. 

In pregnancy a physiological amenorrhoea is the 
rule, while menstruation is increased or irregular in 
fibroids. The uterus is symmetrically enlarged, 
and other signs of pregnancy are present. When 
a fibroid tumor exists with pregnancy, a diagnosis 
is sometimes very difficult. Then the enlargement 
is greater than the stage of the pregnancy will ac- 
count for. Hearing the fetal heart beat makes the 
diagnosis of pregnancy conclusive. 

Pelvic hematocele is of sudden occurrence and is 
accompanied by acute symptoms, and the tumor is 
sensitive and at first semifluid. 

Flexions can be diagnosed by bimanual exami- 
nation and the absence of the fundus from its nor- 
mal position. 

Solid ovarian tumors can be moved without af- 
fecting the position of the uterus, and the depth of 



150 

the uterine cavity is not increased. In some such 
cases a diagnosis is almost or altogether impossible. 

If the fibroid is subserous or pedunculated and 
between the layers of the broad ligament, a diag- 
nosis is very difficult. They are usually harder 
than other tumors in this location, not so tender as 
tumors from disease of the tubes, and the acute pain 
and other symptoms of extra-uterine gestation are 
absent. 

In cancerous troubles there are early ulceration, 
offensive discharges, greater pain, the history of the 
tumor being of comparatively recent occurrence, 
and the development of the cancerous cachexia. 

Prognosis. — While fibroid tumors are perfectly be- 
nign tumors, the possibility of their causing death 
must not be forgotten. Death has occurred from 
hemorrhage; from asthenia; from some change in 
the tumor — as suppuration, gangrene, or malignant 
degeneration ; or from pressure upon the ureters or 
intestines. It is true that many cases of fibroid tu- 
mors give rise to no symptoms whatever. Sponta- 
neous cure has resulted from the involution follow- 
ing pregnancy or the expulsion of a polypus. In 
many cases they cease to develop and sometimes 
atrophy after the menopause, but in some instances 
the climacteric is indefinitely delayed by them. 

Osteopathic treatment gives relief in nearly all 
cases. Some cease to enlarge; others become 



151 

smaller ; and but very few, if any, entirely disappear. 

Treatment. — All lesions are to be removed. Hem- 
orrhage and leucorrhoea are treated by the usual 
methods. Pressure symptoms are relieved by rais- 
ing and loosening up the tumor as much as possible 
and correcting any uterine displacement that may 
be caused by it. Direct treatment to the tumor is 
of value in relieving congestion and decreasing its 
size by absorption. 

Inhibition over the lumbar and sacral regions is 
valuable in relieving suffering and equalizing the 
circulation. 

If the patient does not improve after persistent 
treatment and the symptoms become alarming, have 
her consult a surgeon. It must be remembered 
that, as a rule, the menopause has a favorable effect 
upon the disease. 

MALIGNANT TUMORS OP THE UTERUS. 

These are called " malignant " because of their 
rapid growth ; their tendency to return after removal, 
to involve surrounding "issues, to produce severe 
constitutional symptoms ; and their comparatively 
short course, which ends in death. 

They are, in their order of frequency, carcinoma 
and sarcoma. 

Carcinoma, or cancer, is a malignant growth com- 
posed of nests of epithelial cells and connective 
tissue arranged in variable proportions. 



152 

Cancer of the uterus is more common than cancer 
of any other organ, about one-third of all fatal cases 
occurring here. It is a disease of adult life, nearly 
all cases occurring between the ages of thirty and 
fifty years, being especially prevalent in the few- 
years just before and after the menopause. The 
disease has occurred, but is extremely rare, before 
the age of twenty years. An hereditary predisposi- 
tion is not uncommon, and cancer sometimes occurs 
in those persons whose constitutional resistance is 
weakened by a tubercular or syphilitic ancestry. 
It is less frequent among the better classes than 
among the poor, whose lives are made up of fre- 
quent childbearing, worry, hard labor, and poverty, 
which induces poor nutrition. Injuries or disease 
of the cervix seems to be especially causative, and 
for this reason the disease is more frequent in mul- 
tipara, although cancer of the body of the uterus 
sometimes occurs in nullipara. The disease is said 
to be less common among negroes than among 
whites. 

Various osteopathic lesions are commonly found ; 
and as this is a disease of perverted nutrition, thev 
are no doubt important, if not the chief, etiological 
factors. 

Cancer of the uterus in the majority of cases pri- 
marily affects the cervix and usually occurs in one 
of three forms: 



153 

i. Nodular. In this form small nodules develop 
beneath the mucous membrane and infiltrate the 
muscular tissue of the cervix. These nodules soon 
break down and form ulcers. The diseased process 
may be extensive and limited to the cervix without 
appearing at the os or involving the body. Occa- 
sionally it may extend upward and affect the body. 

2. Papillary. In this form there is a cauliflower- 
like growth from the cervix, which may fill the 
whole of the upper part of the vagina. The tissue 
is very friable and bleeds easily. 

3. Ulcerative. In this form there is a superficial 
infiltration of the mucous membrane, which soon 
breaks down and forms a superficial ulcer. 

Some cases will be met with which cannot be 
positively placed in either of these classes. The 
tendency of all is toward breaking down of tissue, 
ulceration, and involvement of surrounding struc- 
tures ; and when this occurs, it is impossible to say 
what was the original form. 

Symptoms. — Unfortunately, many cases of cancer 
are well developed before the severity of the symp- 
toms induces the patient to consult a physician. 

Hemorrhage is one of the first symptoms, but it 
may not be sufficient to excite suspicion of disease 
until ulceration has occurred. There may at first 
be menorrhagia and, later on, metrorrhagia, or, what 
is more suggestive of cancer, a return of the flow 



154 

after the menopause. In other cases the first indi- 
cation of hemorrhage may follow coition or some 
unusual exertion, or there may be a blood-streaked 
leucorrhoea. 

Another constant symptom is a discharge, which 
at first may be serous, clear, and odorless. After 
ulceration occurs, it becomes more profuse, slightly 
colored, and has a peculiar, sickening, and very 
offensive odor. It is very irritating, and causes ex- 
coriation and intense pruritus of the parts over 
which it flows. 

Pain. — In the beginning this is slight or absent. 
As the tumor grows, as a result of the infiltration of 
the uterine tissue, the pelvic connective tissue, or 
the peritoneum, and as a result of pressure, the pain 
becomes continuous and severe. Ordinarily it is 
constant and of a burning or shooting character 
throughout the pelvis. Pain in the back and neu- 
ralgic pains in the legs are frequent. If the body 
is involved, it may be cramplike in character from 
the efforts of the uterus to expel masses of the 
broken-down tissue. In rare instances pain is but 
slight, or even absent, throughout the disease. 

From extension of the disease the anterior vaginal 
wall and the bladder are finally affected, and cys- 
titis, with frequent and painful urination, will be 
caused. The ureters may be partially obstructed, 
leading to hydronephrosis ; and if the obstruction be 



155 

complete, anuria, uraemia, and death will result. 
Fistulae may result from ulceration between the 
vagina and rectum or bladder. 

The general condition may remain good for some 
time; but it invariably succumbs to hemorrhage, 
digestive disturbances, and toxaemia — the cancer- 
ous cachexia. There is progressive loss of flesh 
and strength, and the skin assumes a dirty-yellow 
and apparently bloodless tinge. 

Anorexia, a disagreeable taste in the mouth, eruc- 
tations, thirst, nausea, vomiting, and constipation 
are common. Diarrhoea may be present in the late 
stages of the disease. 

Edema of the legs, or ascites, is sometimes caused 
by pressure on the return circulation. The deterio- 
ration of the blood and general weakness are also 
factors in this. The pelvic and inguinal lymphatic 
glands are enlarged. Metastatic growths are rare. 

Diagnosis. — This is most difficult at a time when 
a correct diagnosis is most to be desired — in the be- 
ginning. 

On a vaginal examination the cervix will be found 
to be enlarged and, except in the papillary form, 
hard and nodular, frequently resembling the condi- 
tion found in long-standing lacerations, with en- 
dometritis. In the papillary form the cauliflower 
excrescence will be found occupying the upper por- 
tion of the vagina. In this condition the tissue is 



156 

softer, but in all cases i? is very friable and bleeds 
upon slight violence or manipulation. 

After ulceration has occurred, the diagnosis is 
easier. Here the ulcer (with sharply-defined and 
hard edges), the friable tissue, and the tendency to 
bleed from trivial causes; and, later on, the fixity 
of the uterus, the infiltration and hardening of the 
vaginal vault, the involvement of the inguinal or 
pelvic glands, the history, the age of the patient, 
and other local and general symptoms — these usu- 
ally make the diagnosis easy. 

In doubtful cases a specimen of the growth 
should be submitted to a competent pathologist for 
a microscopical diagnosis. 

The diseases causing most difficulty in diagnosis 
are lacerations of the cervix, with endometritis ; 
fibroids, or polypi, especially if sloughing. 

In the former disease there is a lack of so great 
friability of tissue and tendency to hemorrhage ; the 
line of demarcation between the diseased and 
healthy tissue is not so prominent; the hyper- 
trophied follicles (ovula of Naboth) are usually 
present ; and on a visual examination the erosion is 
seen not to be a true ulceration. Besides, this can- 
cer occurs near the menopause ; is not a disease of 
long duration ; and has with it the fetid discharge, 
greater liability to hemorrhage, and constitutional 
symptoms. 



157 

In cases of fibroids and polypi the enlargement 
of the uterus is at the fundus, or the polypus can 
usually be felt through the cervix. Such troubles 
are less frequent after the menopause ; the uterus is 
movable; the tumor is of long standing; and the 
symptoms of sloughing, when present, are rather 
acute in their onset. 

Prognosis. — This is bad, or (if the disease is not 
discovered until it is well advanced) hopeless. 
Death usually results in from six to twenty-four 
months, either from exhaustion and uraemia or peri- 
tonitis. Exceptionally the disease may last for from 
five to seven years, and a very few cases of spon- 
taneous cure by the cancerous tissue sloughing out 
are reported. 

Treatment. — This should be surgical in those 
cases in which the w T hole of the diseased tissue can 
be removed. Cancer is a local disease, and, if en- 
tirely extirpated, does not return ; but if even a few, 
a microscopic mass, of the cancer cells survive the 
operation, the trouble will return. 

Osteopathic treatment has cured some apparent 
cancers. Such cures may have been of true cancers 
or cases in which the diagnosis was at fault. Theo- 
retically they should be cured by such treatment, 
but often they are of such rapid growth and malig- 
nancy that total excision is best if it can be accom- 
plished. 



158 

In the cases not admitting of an operation, reduc- 
tion of lesions, the relief of pain, and the control of 
hemorrhage are achieved by the usual methods. The 
patient should also have general treatment, nutri- 
tious food, and good hygienic surroundings, so that 
the general health may be built up in every possi- 
ble manner. 

Deodorant douches should be given for dis- 
charges. 

CANCER OF THE BODY OF THE UTERUS. 

This occurs in only from two to three per cent of 
cancers involving this organ. It has symptoms 
similar to those of cervical cancer. It is not so 
easily diagnosed by vaginal examination. The 
body of the uterus is enlarged, the cavity is deep- 
ened, probing is followed by hemorrhage, and there 
may be passed masses of the cancerous tissue. All 
that applies to treatment and prognosis of cancer 
of the cervix is applicable here, except that it is 
more rapidly fatal. 

SARCOMA. 

This is a tumor formed of an irregular growth 
of connective tissue and embryonal cells. It is usu- 
ally located in the body of the uterus, and affects the 
cervix but rarely. It is most frequent between 
the ages of forty and fifty years, but may occur 



159 

at any age, and has been observed as a congenital 
growth. It is sometimes called the " cancer of 
youth. " Many of the women affected by it are 
nulliparous. Its cause is no better known than is 
that of carcinoma. 

Symptoms. — These begin somewhat similar to 
those of fibroid tumors, with hemorrhage, watery 
leucorrhoea, and pain. The uterus is enlarged, and 
perhaps nodular. The cervix may be dilated, and 
through it the growth can be felt, or it may be 
forced down through the os by uterine contractions. 
The pain is often expulsive in character, and also 
results from pressure and involvement of the sur- 
rounding tissues. Pieces of diseased tissue may be 
expelled from the os. The growth of the tumor is 
rapid. 

A bloody, offensive discharge and cachectic symp- 
toms soon appear. 

The diagnosis from fibroids is sometimes difficult. 
The tumor is of more rapid growth and occurs at 
the menopause, a time when fibroids cease to grow. 
The tumor is not so firm as a fibroid, and the pain 
is more violent. Pieces of tissue may be passed 
or the soft and ulcerating tissue may be felt through 
the os. The discharge is sero-sanguineous and 
fetid. The loss of flesh and strength and appear- 
ance of cachexia exclude the possibility of a fibroid. 

From carcinoma of the body the diagnosis may 
be impossible. 



160 

From chronic endometritis the diagnosis is made 
by age, endometritis occurring at any age, but not 
after the menopause ; the uterus is not markedly en- 
larged; tenderness is slight or absent; there is no 
cachexia ; a sero-sanguineous discharge is rare ; and 
the os is usually closed. 

Prognosis and Treatment. — See " Carcinoma of the 
Uterus." 



CHAPTER XI. 



Diseases of the Ovaries. 

DEFECTIVE DEVELOPMENT. 

Congenital absence of one or both ovaries occurs, 
and is usually associated with deficient develop- 
ment of the remaining sexual organs and always 
with derangement of their function. 

When both ovaries are absent, the usual changes 
of puberty do not occur; the girl does not develop 
into the physical perfection of womanhood; and 
often mental inertia and depression, and sometimes 
a condition akin to idiocy, prevails. 

Rudimentary development is more common, and 
may affect one ovary, but usually both ovaries. This 
is also associated with defective development of the 
other genital organs and with disturbed mental and 
physical maturity. Such a condition is sometimes 
seen in female epileptics. 

Supernumerary ovaries are occasionally found. 
161 



162 

When the ovaries are congenitally absent, no 
treatment is able to develop the sexual functions; 
if they are rudimentary, but little can usually be ac- 
complished. 

CONGESTION OF THE OVARIES. 

Congestion is physiological during menstruation 
and coition; but if excessive or continued, it be- 
comes pathological. Continued passive ovarian 
congestion is nearly always, if not always, a part of 
a general pelvic congestion, because of the free 
anastomosis between the blood vessels of all the 
pelvic viscera. 

Causes. — i. Osteopathic lesions, particularly those 
affecting the ninth to the twelfth dorsal vertebrae 
and the corresponding ribs. 

2. Conditions causing pelvic congestion — uterine 
displacements or disease, pelvic inflammation or 
adhesions, diseases of the heart or lungs, and dete- 
riorated blood conditions, as in fevers, mineral 
poisoning, septicaemia, etc. 

3. Close confinement and lack of proper exercise 
at the commencement of menstruation. This is 
seen in ambitious schoolgirls and in those of indo- 
lent and luxurious habits. 

4. Masturbation, excessive venery, and ungratified 
sexual desire. 

5. Displacement of the ovary. 



163 

Symptoms. — There is constant pain or tenderness 
over one or both ovaries, more often the left ovary. 
The pain is more severe preceding the menstrual 
period, radiates down the thighs or to the back, 
and is relieved by the flow, which is usually pro- 
fuse. A sympathetic pain in the breast is frequent. 
There is no fever present. 

As a result of the intense congestion occurring 
at menstruation, hemorrhage may occur into a 
Graafian follicle and the tissue of the ovary. This 
is called " follicular apoplexy " or " ovarian apo- 
plexy/' and may cause considerable enlargement of 
the ovary and severe pain, with nausea and vomit- 
ing. The extravasated blood may be absorbed, or 
the ovarian tissue may rupture and copious bleed- 
ing take place into the peritoneal cavity, giving rise 
to the formation of a hematocele in Douglas' pouch 
and symptoms of shock and acute anemia. 

Treatment. — If the congestion be dependent upon 
osteopathic lesions, these should be removed, with 
all causes producing pelvic congestion. Sexual ex- 
citement of an}' kind, especially coition, should be 
prohibited until congestion is relieved. The patient 
should go to bed a few r days before the expected 
period and remain there until the flow ceases. Gen- 
eral relaxation and inhibition of the lower dorsal 
and lumbar region will relieve pain and congestion. 
Build up the general health, and have the patient to 



164 

take ample outdoor exercise, form regular habits in 
regard to eating and sleeping, and avoid all forms of 
excitement. 

DISPLACEMENTS OF THE OVARY. 

One or both ovaries are occasionally found in 
abnormal positions outside the pelvic cavity. From 
failure to descend, one may remain in the lumbar 
region, or it may be contained in an inguinal, femo- 
ral, ventral, or more unusual form of hernia. The 
ovaries may become diseased in their abnormal sit- 
uations. However, these conditions are rare. 

PROLAPSE OF THE OVARY. 

This is not uncommon, and may affect one or 
both ovaries, most frequently the left ovary, because 
of its anatomical predisposition to congestion and 
increase of weight. 

The affected ovary drops downward, backward, 
and toward the median line, and is, as a rule, found 
in Douglas' pouch, sometimes as low as the level 
of the external os. 

Causes. — i. Osteopathic lesions, by causing relax- 
ation of pelvic tissues, passive congestion, and in- 
crease in weight of the ovary. 

2. Uterine displacements. These not only cause 
congestion, but retro-displacements also draw the 
ovary downward and backward. 



165 

3. Increase of weight, as from tumors, conges- 
tion, inflammation. 

4. Traction. This may be from adhesions or en- 
larged tubes adherent to the ovary. 

5. Subinvolution. This not only destroys normal 
tonicity, but leaves the tissues congested and heav- 
ier than normal. 

A fall or a violent muscular effort may be neces- 
sary as a determining cause in the presence of the 
foregoing as predisposing causes. 

Symptoms. — As a result of the abnormal position 
and consequent obstruction to circulation, conges- 
tion and inflammation, if not among the causes, are 
produced and cause their usual symptoms. 

Pain is constant, and is felt in the sides of the pel- 
vis, the lower part of the back, the sacrum, or the 
rectum. It often radiates down the thighs to the 
knees. It is more severe just preceding the men- 
strual flow, and is increased by the passage of hard 
fecal masses, especially by coition and by standing 
and walking. There is a more aggravated sensa- 
tion of weight and heaviness in the pelvis than ac- 
companies uterine displacements. 

Gastric and nervous symptoms, malaise, and 
mental depression are common. 

Dysmenorrhoea and menorrhagia are frequently 
present. 

On pressure over the ovary or on bimanual pal- 



166 

pation, a weakening, nauseating pain is caused. 

Diagnosis. — This is made by the presence of an 
enlargement in Douglas' pouch, its shape, relation 
to the uterus, absence of the ovary from its normal 
position when it can be detected, and the peculiar 
sensation of faintness and nausea when the tumor 
is pressed upon. 

Prognosis. — This depends upon the complicating 
conditions, as congestion, inflammation, degener- 
ative changes, and adhesions. If these are pres- 
ent, the prognosis depends upon whether or not they 
can be removed, as replacement will not be per- 
manent unless they are cured. 

Treatment. — This should be directed to the re- 
moval of cause and complications. Lesions are 
to be reduced, tissues toned up, and all adhesions 
relaxed by treatment to proper centers and appro- 
priate local treatment. With each local treatment 
the ovary should be loosened up ; and if it is not 
too sensitive, attempts at replacement should be 
made. This is done by the bimanual method in the 
dorsal position, and in some cases better results 
may be gained by using the fingers of one hand, 
with the patient in the knee-chest or left-lateral 
position. Replacement may have to be repeated a 
number of times before it becomes permanent. 

Have the patient to occupy the knee-chest posi- 
tion several minutes before retiring, and give deep- 
breathing and chest-expanding exercises for effect 



167 

on pelvic circulation. The ovary will now often 
spontaneously return to its normal position. 

OVARITIS, OR OOPHORITIS. 

This is an inflammation of the ovaries, and occurs 
in an acute, but more frequently in a chronic, form. 

Acute ovaritis may occur in one or both ovaries, 
and may originate in the peritoneal covering of the 
ovary, peri-ovaritis ; or in the stroma of the organ, 
ovaritis proper. 

Causes. — I. Osteopathic lesions. These are great 
predisposing causes by producing defective innerva- 
tion and derangement of normal vascular conditions. 

2. Inflammation of the mucous membrane of the 
uterus and tubes. This may be simple, septic, or 
specific, and, by extension, involve the ovaries. 

3. Menstrual suppression, as from cold, wet, etc. 

4. Septic infection through the lymphatics from 
parturition, minor gynecological operations, instru- 
mental examinations, etc. 

5. Constitutional diseases — eruptive fevers, chol- 
era, mumps, septicaemia, etc. 

Pathology. — The affected organ is enlarged and 
tender. In ovaritis its tissues are infiltrated by 
round cells and serum. The inflammation may pro- 
gress to suppuration, especially in cases due to 
puerperal or gonorrhoeal infection. The inflam- 
mation may be less acute and the organ remain en- 



168 

larged from the formation of connective tissue with- 
in its stroma, which may subsequently contract and 
leave the ovary in a more or less atrophied condi- 
tion. In peri-ovaritis there is an inflammation of 
the capsule of the ovary, which extends more or less 
to the surrounding peritoneum. The organ is en- 
larged, tender, and surrounded by adhesions. 

Symptoms. — These are frequently overlooked or 
ascribed to the accompanying salpingitis or peri- 
tonitis. As a rule, there is severe pain in the iliac 
fossa on the affected side. The pain may radiate 
to the rectum, the sacrum, the bladder, and down 
the thigh to the knee. There is a rise of fever, 
sometimes there is a chill, and frequently there are 
nausea and vomiting. Should an abscess develop, 
there will be irregular chills, fever, and sweats ; in 
rare instances fluctuation may be elicited. Pressure 
over the ovary causes severe pain, and on bimanual 
pressure the pain is intense. The ovary is found 
enlarged to the size of a hen's egg or larger. 

Diagnosis. — This is sometimes difficult. The lo- 
cation, the enlargement of the ovary, and the symp- 
toms, especially if the ovary is spherical in outline, 
tender, and the uterus is freely movable, will make 
the diagnosis fairly certain. Salpingitis, hydro- 
salpinx, and pyo-salpinx form sausage-shaped tu- 
mors. 

Prognosis is favorable. If an abscess does not 



169 

form, the inflammation subsides in less than a 
week ; if abscess formation should occur, the greater 
part of the ovary may be destroyed and sterility 
result, or life may be threatened by infection of the 
peritoneum. The possibility of prolapse from in- 
creased weight, the formation of adhesions, and 
recurrence of the attack must be considered. 

Treatment. — The patient must be confined to bed, 
the bowels freely moved by warm enemeta, and an 
ice bag applied to the iliac fossa over the affected 
ovary. Occasionally hot applications are more 
grateful to the patient, and are then to be preferred. 

The lower dorsal and upper lumbar regions 
should be gently relaxed, followed by inhibition to 
relieve pain and congestion. Should an abscess 
form and give rise to septic symptoms, the pus must 
be evacuated. If this is not done, rupture and peri- 
tonitis sometimes occur. Rupture of the abscess 
usually takes place through the intestines, vagina, 
bladder, orVectum. 

CHRONIC OVARITIS. 

This is a chronic inflammation of the ovaries 
found more frequently associated with chronic in- 
flammation of the pelvic peritoneum and connective 
tissues than as a disease of the ovaries alone. 

Both organs may be involved; but when the dis- 
ease is unilateral, the left ovary is more frequently 



170 

affected. This is because of its proneness to con- 
gestion, the left ovarian vein having no valve, open- 
ing into the renal at right angles, and is subject to 
pressure from fecal matter in the lower bowel. 

The disease is most common in married women 
and during the age of sexual activity. 

Causes. — I. Osteopathic lesions, especially from 
the ninth to the twelfth dorsal vertebrae and to the 
corresponding ribs. These affect the innervation of 
the ovaries and cause congestion, which may be 
either the active or the predisposing cause of 
chronic ovaritis. 

2. Pelvic inflammation, especially gonorrhoeal or 
puerperal. Endometritis, salpingitis, cellulitis, or 
peritonitis may cause ovaritis by extension — the 
two former, by extension through the tubes ; the 
latter, by contiguity of tissue. 

3. Uterine displacements, by causing congestion, 
and especially retroversion, which also displaces 
the ovaries. 

4. Prolapse of the ovary, by irritation and con- 
gestion. 

5. Acute ovaritis, particularly repeated attacks. 

6. Intemperate coitus, masturbation, or unsatis- 
fied sexual desire. 

7. Agencies producing continued pelvic conges- 
tion — heavy lifting, sewing on machine, alcoholism, 
and heart, lung, or kidney disease, 



171 



Pathology. — In the early stages of the disease the 
ovaries are enlarged to two or three times their 
natural size, and are greatly congested. This en- 
largement may continue throughout the course of 
the disease, or the ovary may become smaller than 
normal, imbedded in adhesions, which alone, or with 
the contraction of new inflammatory tissue in the 
stroma of the organ, has caused the atrophy. Cys- 
tic degeneration is not uncommon. The cysts may 
be small and multiple, or one large cyst may form 
and, by pressure, cause atrophy of the ovarian 
tissue, a true ovarian cyst being formed. The cysts 
originate from the corpora lutea and from Graafian 
follicles, which are prevented from rupture by being 
deep seated, covered with inflammatory material, or 
because of insufficient menstrual congestion to 
cause their normal rupture. Waxy degeneration of 
the ovary sometimes occurs. 

Symptoms. — These are frequently vague and 
masked by attendant conditions. Pain is constant ; 
is most severe in the groin, more frequent on the 
left side; and radiates down the thigh to the knee, 
to the sacrum, to the rectum, or to the bladder. It 
is increased by any jolt or jar, often by micturition 
or defecation, by coition if the ovary is prolapsed, 
and sometimes makes standing or walking for even 
a very short time difficult and painful. The pain 



172 

is always more severe preceding menstruation, 
sometimes several days before, and is relieved if the 
flow is profuse, but continues when the flow is 
scanty. 

Sympathetic pains are often felt in the breasts. 
The ovaries are tender on abdominal or bimanual 
pressure. 

Irregular or profuse menstruation is common ; 
but if there is great destruction of ovarian tissue, 
amenorrhoea and sterility will result. 

Leucorrhoea is present, and is a symptom of gen- 
eral pelvic congestion. 

The nervous system is sometimes profoundly 
affected. Irritability, attacks of mental depression, 
hysterical tendencies, true hysteria, hystero-epi- 
lepsy, or true epilepsy may develop. 

Digestive disorders and the effects of malnutri- 
tion are constant in cases of long standing. 

Diagnosis. — This is made from a history of pelvic 
inflammation, tenderness and enlargement of the 
ovary (which increases before menstruation), pre- 
menstrual pain, the presence of adhesion about the 
ovary, the general symptoms, and the location of 
the osteopathic lesions. 

Prognosis. — Good, so far as life is concerned. 
Nearly all cases are benefited; many are cured. 
Several months' treatment may be necessary. 

Treatment, — This, of course, begins with the loca- 



173 

tion and removal of the causes of the trouble and 
the relief of pelvic congestion. 

Pain is relieved by relaxation and inhibition of 
the ovarian centers. The general nutrition should 
be improved in every possible manner, general 
treatment, restoration of digestive function, easily 
digestible and nutritious diet. The patient should 
rest in bed during the menstrual period. Sexual in- 
tercourse should be prohibited. 

Local treatments should be given cautiously and 
very gently at first. There should be a gentle, re- 
laxing bimanual treatment, which, with spinal inhi- 
bition, will relieve congestion, pain, and soreness. 
The pelvic tissues should be raised by treatment 
through the abdominal wall by the manipulation 
given for stretching the broad ligament. 

As soon as the pain and tenderness are suffi- 
ciently relieved, treatment should be given to the 
ovary to release it from surrounding adhesions and 
restore it to its proper position. 



CHAPTER XII. 



Neoplasms of the Ovary. 

Ovarian tumors are either cystic or solid. Of the 
cystic growths there are simple, proliferating, and 
dermoid cysts. The solid growths are more rare, 
and include fibroid tumors, sarcomata, and carcino- 
mata. 

Cysts may develop from any part of the ovarian 
structure. 

Cause. — Little is known of the cause of ovarian 
cysts. They appear at all ages, but are more com- 
mon between the ages of twenty and fifty years, the 
period of sexual activity. Dermoid cysts are the 
most frequent variety appearing before puberty. 
They are all more common in nullipara, probably 
because there is no relief from continued menstrual 
congestion by pregnancy and lactation. Unceasing 
menstruation causes a hypernutrition of the pelvic 
viscera that sometimes, manifests itself as a morbid 
growth. An hereditary predisposition is occasion- 
174 



175 

ally observed. Chronic ovaritis and deficient men- 
strual congestion by not allowing the rupture of the 
Graaffian follicles are thought to be causative. 

Osteopathic lesions, especially from the ninth to 
the twelfth dorsal vertebrae and to the correspond- 
ing ribs, are constant, and are doubtless the chief 
causes of these tumors, because of the intimate sym- 
pathetic relationship between these structures and 
the ovaries. 

Simple Cysts. — These result from the dilatation of 
unruptured Graafian follicles, and rarely grow 
larger than an orange, or, at the utmost, as large as 
an adult head. They are bilateral, as a rule, and 
are filled with a clear, serous, bland, alkaline fluid. 

Another form of the simple cyst is that develop- 
ing from a corpus luteum. These are of slow 
growth, rarely attain a size larger than an orange, 
are composed of a multitude of small cysts, pedun- 
culated, bilateral, and have an appearance suggest- 
ive of a bunch of grapes. 

Tubo-ovarian are simple cysts that result from 
the adhesion of a hydro-salpinx to a cystic ovary. 
The tissue between the two becomes absorbed, and 
the two cavities unite into one. The os uterinum 
usually remains open, and the cyst may from time 
to time empty itself and its walls collapse. Such 
cysts do not reach a large size, and are unilateral. 

Proliferating Cysts. — These are so called because 



176 

of their property of increasing in size by the forma- 
tion of new C}'Sts or growths within the original 
cyst. They are of two varieties — glandular and 
papillary. 

Glandular proliferating cysts are the most fre- 
quent of ovarian growths, most rapid in develop- 
ment, and in size range from a walnut to a tumor 
weighing as much as one hundred and forty-nine 
pounds. 

Owing to their method of formation they are al- 
ways at first multilocular, but, by the absorption of 
partitions, may become unilocular. The unilocular 
tumors are usually smooth ; the multilocular, nodu- 
lated. The ovarian tissue is destroyed when they 
reach the size of the fist. They are nearly always 
pedunculated and bilateral. 

They are filled with fluid, which may be clear or 
discolored, from the slightest tinge of yellow to 
black, and in consistence may vary from that of 
water to semisolidity. The fluid contains epithelial 
cells, red blood corpuscles, white blood corpuscles 
intact and in various stages of disintegration, be- 
sides cholesterin and indican. 

Papillary proliferating cysts are not so common. 
They neither grow as rapidly nor attain so great 
size as the glandular cysts. From their inner sur- 
face warty growths, or papillomas, grow. These 
may not only fill the cyst, but rupture its walls and 



177 

infect the surrounding structures. Ascites is often 
associated with this form. 

Dermoid Cysts. — These are thought to be caused 
by the invagination of epiblastic cells during the 
fetal development of the ovary. This is probable, 
as it is from epiblastic cells that normal tissues, ab- 
normal counterparts of which are found in dermoid 
cysts, are formed. The inside of the sac of a der- 
moid cyst resembles skin both in appearance and 
histological structure. Papillae, sudoriferous and 
sebaceous glands, hairs, teeth, cartilage, bone, and 
unstriped muscular tissue are frequently found in 
these tumors ; and even mucous membrane, mam- 
mae, apparent brain tissue, a metacarpal bone and 
articulations, a trachea, a partially formed heart, 
and an eye have been found. Besides these, there 
is a thick fluid containing cholesterin and abundant 
fat, which may be in globules or in solid masses. 

Dermoids are rarely larger than an adult head, 
though two or three may develop from the same 
ovary. They are usually, though not invariably, 
unilateral. They have been found at all ages be- 
tween birth and the age of ninety years. They are 
the most frequent form of ovarian tumor occurring 
before puberty, and are sometimes associated with 
defective development of the generative organs. 

Ovarian cysts of all varieties are usually peduncu- 
lated, the pedicle being formed of the ovarian liga- 



178 

ment, the Fallopian tube, and part of the broad 
ligament, with the accompanying blood vessels, 
nerves, etc. Torsion of the pedicle sometimes oc- 
curs with the production of disastrous consequences. 
Occasionally the tumors develop between the layers 
of the broad ligament and grow downward, in 
which case there is no pedicle. 

Adhesions form more frequently than in fibroid 
tumors of the uterus. They occur when there is a 
loss of epithelium covering the tumor. In order of 
frequency they occur between the tumor and the 
abdominal wail, omentum, intestines, bladder, 
uterus, etc. 

Ascites may accompany any variety of ovarian 
cyst, but is most often seen with the proliferating 
papillary. 

When each ovary develops a cyst, the two cysts 
may become adherent, the partition between them 
may be absorbed, and a single cyst (with two ped- 
icles) may be formed. 

All cysts are liable to certain complications or 
changes within their structure, which give rise to 
symptoms peculiarly their own. Such changes 
may be hemorrhage, inflammation and suppuration, 
rupture, calcification, or cancerous degeneration. 

Symptoms. — The tumor may develop insidiously 
and be discovered by accident, or the attention may 
be called to it by the enlargement of the abdomen. 



179 

i his is especially the case when the cyst is peduncu- 
lated and rises into the abdomen. Should it be con- 
fined to the pelvis, it will cause symptoms earlier in 
its course. 

As a rule, more or less pain is experienced, or a 
sense of weight and heaviness or discomfort in 
walking or during the act of sitting down or rising. 
A premenstrual or intermenstrual pain is not un- 
common. Menstrual disorders are not usual at 
first, but later on menorrhagia — or, after uterine tis- 
sue is destroyed, amenorrhoea — may be present. 
In some cases there is a reappearance of the flow 
after the menopause. If both ovaries are destroyed, 
sterility results, and is often produced when only 
one ovary is cystic ; while, on the other hand, preg- 
nancy has occurred when both ovaries were the seat 
of large tumors; but under such conditions abortion 
is probable. 

Pressure symptoms occur when the tumor 
reaches the size of the double fist, if it is retained 
in the pelvis by adhesions or a short pedicle. If the 
tumor rises into the abdominal cavity, pressure 
symptoms make their appearance much later. 

Pressure on the bladder will cause frequent, dif- 
ficult, or painful urination, or even retention of 
urine; on the rectum it causes difficult — and, when 
the tumor is sensitive, painful — defecation; on the 
ureters it leads to hydronephrosis, partial or com- 



180 

plete suppression, and uraemia. Compression of 
the abdominal veins causes edema of the legs, ex- 
ternal genitals or hemorrhoids, and enlargement of 
the superficial abdominal veins. Nausea, vomiting, 
and anorexia will be caused by pressure upon the 
stomach, and jaundice may result from pressure 
upon the bile ducts. 

Neuralgic pains in the legs result from pressure 
upon the lumbo-sacral nerves. 

Abdominal enlargement usually begins in one 
iliac fossa, but finally extends over the entire ab- 
domen. The enlargement reaches the greatest de- 
gree and is most rapid in the glandular proliferating 
cyst. As the tumor grows larger and heavier, the 
patient leans backward in walking so as to preserve 
her center of gravity. The tumor may become so 
large that walking is impossible, and she cannot 
lie in the dorsal position, but is compelled to lie 
on her side and to be turned by her attendants. 

Enlargement of the breasts, and even the secre- 
tion of milk, is sometimes seen. 

Various displacements of the uterus result, ac- 
cording to the direction in which it is pressed or 
dragged by the cyst. 

The general health soon fails. The patient be- 
comes emaciated and weak; her features become 
pinched and furrowed, giving her a characteristic 
facial expression. If not relieved, death ultimately 



181 

results. It may be from marasmus and asthenia, 
impeded heart and lung action, intercurrent disease 
of the respiratory organs, nephritis, hydronephrosis, 
or complications occurring in reference to the cyst 
itself, as hemorrhage, inflammation and suppura- 
tion, rupture, torsion of the pedicle, intestinal ob- 
struction, or cancerous degeneration. 

Hemorrhage may result from torsion of the ped- 
icle, injury, rupture, erosion of blood vessels, or 
ulceration. If it is small in amount, it will give rise 
to no symptoms ; but if copious, there will be an in- 
crease in the size of the tumor and symptoms of 
shock and acute anemia. 

Inflammation and suppuration are the conse- 
quence of infection from the intestine, bladder, Fal- 
lopian tubes, or from tapping. They cause pain and 
tenderness over the tumor and fever. Irregular 
chills, fever, and sweats are indicative of suppura- 
tion. 

Rupture may be sudden from an injury or fall or 
may result from a gradual change in the cyst wall. 
It occurs either into the peritoneal cavity, one of the 
abdominal or pelvic viscera, or through the abdom- 
inal wall. If into the peritoneal cavity, as is usual, 
and the fluid is unirritating, it may be followed only 
by a profuse diuresis. Even when the cyst contents 
are hemorrhagic, it may give rise to no serious symp- 
toms. Should the cyst contain pus or be a dermoid, 



182 

peritonitis is caused. If it is a proliferating pap- 
illary cyst, infection of the peritoneum occurs. 
Should rupture occur into any viscus, there will be 
symptoms referable to that particular organ and 
the passing of the cyst contents from it. Rupture 
is said to occur in from eight to ten per cent of cases. 

Torsion of the pedicle occurs in about ten per 
cent of cases, and most frequently in dermoids. 
There may be any degree of twisting, from a half 
turn to several complete turns. It may be caused 
by a change in position, exercise, peristaltic intesti- 
nal movements, filling and emptying of the bladder, 
etc. The effects depend upon the amount of ob- 
struction to the circulation. It may occur gradu- 
ally, without giving rise to pronounced symptoms : 
or it may occur suddenly, and cause sudden and 
severe pain, enlargement of the tumor, and incessant 
vomiting. If the twist is not relieved, it may lead 
to inflammation and suppuration, rupture, hemor- 
rhage, ascites, peritonitis, or gangrene of the cyst. 

In more chronic cases there will be continuous 
pain, enlargement of the cyst, and a gradual deterio- 
ration of health. 

Intestinal obstruction may be caused by direct 
pressure of the tumor, by adhesions, by involve- 
ment of the intestines in a twist of the pedicle, or 
may result from rupture or puncture of the cyst 
when it has become adherent to the intestines, the 



183 

collapse of the cyst causing distortion of the gut 
and consequent obstruction. 

Cancerous degeneration is said to occur in at least 
one-fifth of all ovarian tumors. 

Ascites is often present, but is rarely abundant, 
except in cases of torsion of the pedicle, peritonitis, 
rupture, or malignant degeneration. 

Peritonitis is caused occasionally by friction and 
consequent irritation of the tumor or from torsion 
or rupture. Adhesions are likely to form which 
complicate the condition. 

Diagnosis. — When the tumor is small and con- 
fined to the pelvis, its presence can be determined 
by a bimanual examination. If not larger than a 
hen's egg and not bound down by adhesions, it is 
usually found behind the uterus, but may be an- 
terior or lateral to it. As the tumor enlarges, the 
uterus will be displaced by it. If pedunculated, the 
movement of the tumor has but little or no effect 
upon the uterus. Small tumors feel firm, circum- 
scribed, and can be felt as bodies separate and dis- 
tinct from the uterus, especially by a recto-abdomi- 
nal examination. When developing between the 
layers of the broad ligament, the growth is not so 
movable, spherical, or circumscribed. 

As growth continues, on abdominal palpation an 
enlargement may be felt in the iliac fossa. It may 
be round and smooth or nodular, and gives a sensa- 



184 

tion of elasticity. It is mobile, and is dull on per- 
cussion. As the tumor rises out of the pelvis, the 
abdomen enlarges, beginning in the iliac fossa and 
finally becoming general. 

Small tumors must be differentiated from hydro- 
salpinx, pyo-salpinx, extra-uterine pregnancy, cellu- 
litis, peritonitis, and hematoma. 

In hydro-salpinx there is a history of previous in- 
flammation and a sausage-shaped or gourd-shaped 
tumor ; in pyo-salpinx there are added to these ten- 
derness and evidences of inflammation in the sur- 
rounding pelvic tissues, as thickening of the tube 
and adjacent structures. 

Extra-uterine pregnancy gives the usual symp- 
toms of pregnancy, attacks of sudden and violent 
pelvic pain, often a slight bloody discharge, and ex- 
pulsion of the decidual membranes. 

Cellulitis and peritonitis have a history of inflam- 
mation; the swelling is produced more rapidly, is 
immovable, and is more diffuse. 

Hematoma is sudden in appearance, is accompa- 
nied by symptoms of shock and hemorrhage, and 
soon disappears by absorption. 

So many mistakes have been made by eminent 
diagnosticians in ovarian tumors that a diagnosis 
should always be guarded. The conditions with 
which larger tumors have been confused and their 
distinctive symptoms are as follows : 



185 

Pregnancy. — In this condition there are the usual 
sympathetic symptoms of pregnancy, menstruation 
is suppressed, the abdomen enlarges rapidly, the 
general health is good, fluctuation is absent, and 
after the fifth month the fetal heart sounds and 
movements are pathognomonic of the condition. 
When pregnancy is complicated by an ovarian cyst, 
the diagnosis is more difficult. 

Uterine fibroids are of slow growth, hard, nodu- 
lar; are intimately connected with the uterus, so 
that movement of the tumor causes the uterus to 
move ; the uterine cavity is usually deepened ; and 
fluctuation is absent in uncomplicated cases. If 
cystic degeneration of a fibroid occurs, the diagnosis 
may be impossible. 

Ascites has a history of some causative condition ; 
no tumor can be palpated ; the abdomen is flattened 
in the dorsal position ; there is dullness in the 
flanks, which changes with the position of the pa- 
tient ; the uterus is freely movable, but little, if at all, 
displaced ; and fluctuation is easily elicited. 

Tumors of nearly every abdominal organ have 
been mistaken for ovarian tumors, and a diagnosis 
should not be made until by a careful examination 
the presence of tumors of the abdominal organs is 
eliminated. 

Course and Prognosis. — Spontaneous cure has re- 
sulted from calcification of the cyst wall or from 



186 

rupture or torsion of the pedicle. From seventy to 
eighty per cent of proliferating cysts prove fatal by 
the end of four years; while, on the other hand, a 
patient may have an ovarian cyst for a number of 
years without great deterioration of the general 
health. A number of cases of small ovarian cysts 
and several large ones have been reported cured by 
osteopathic means. 

Treatment. — The first indication is to remove all 
osteopathic lesions. The cyst may be treated di- 
rectly, and in the case of small ones much can be 
accomplished by bimanual treatment. Particular 
attention should be given to the return circulation 
from the pelvis. The tumor, if in the pelvis, should 
be loosened by moving it in different directions, 
and gentle pressure may be made upon it if the diag- 
nosis of a simple cyst can be made. The rupture of 
such is usually devoid of disagreeable symptoms, 
but the rupture of a proliferating papillary or a der- 
moid cyst would be very disastrous. 

The general health should receive attention and 
be improved as much as possible. 

If persistent treatment is unavailing, surgical 
means should be employed. The complications of 
torsion, rupture of a dermoid, suppuration, etc., 
would also render surgical procedures imperative. 



187 

SOLID TUMORS. 

Fibroid tumors of the ovaries are rare ; are small 
in size, but may sometimes reach a very large size. 
They have the same physical characteristics as 
fibroids of the uterus, and are liable to the same 
changes and complications. They are usually uni- 
lateral. 

They are more painful than similar tumors of the 
uterus, ascites develops earlier in their course and 
more frequently, and they are in most instances 
freely movable. 

A diagnosis from a pedunculated subserous uter- 
ine fibroid is difficult unless both ovaries can be 
palpated, when, of course, an ovarian tumor is elimi- 
nated. 

The prognosis and treatment is similar to that 
for fibroid tumors of the uterus. 

A sarcoma of the ovary is also rare. It may be 
primary or a secondary change in an ovarian cyst. 
It occurs usually in young persons. 

The diagnosis is difficult. A sarcoma is of more 
rapid growth than a fibroid, and is to be suspected 
when an ovarian cyst grows rapidly in a short time. 

A carcinoma is also rare, particularly as a primary 
growth. It may be secondary, as a malignant de- 
generation of an ovarian cyst or as an extension 
from some other organ, the uterus usually. When 



188 

primary, it is usually bilateral. It rarely grows 
larger than an adult head. 

A carcinoma of the ovary is characterized by 
rapid growth, pain, edema of the legs, ascites, 
metastatic growths, peritonitis, and cancerous 
cachexia. 

The prognosis and treatment of sarcomata and 
carcinomata of the ovaries is similar to that for 
similar affections of the uterus. 



CHAPTER XIII. 



Diseases of the Fallopian Tubes. 

ACUTE SALPINGITIS. 

This is an inflammation of the Fallopian tubes, 
and occurs in a catarrhal and a purulent form. It 
is not an uncommon affection, and occurs during 
the time of sexual activity. 

Cause. — Salpingitis is practically always second- 
ary to disease of the uterus, and results from an 
extension of the uterine disease along the continu- 
ous mucous membrane of the uterus and the tubes. 
In some cases the salpingitis is coincident with, 
rather than secondary to, the uterine disease. It 
may be said that the etiology of endometritis and 
salpingitis is identical. 

The purulent form, the most severe and danger- 
ous, results in nearly every instance from gonor- 
rhoea or puerperal infection, though it may be 
caused by infection during an instrumental exami- 
nation or an operation, and it is possible for a ca- 
189 



190 

tarrhal salpingitis to be infected and become puru- 
lent. 

Malformations or deformities of the tubes or 
previous attacks of inflammation predispose to the 
disease. 

Pathology. — In acute catarrhal salpingitis the in- 
flammation is confined almost entirely to the mu- 
cous membrane. Its folds become swollen, con- 
gested, and infiltrated with new cells. The epi- 
thelium is swollen, some of it is thrown off, and 
the normal secretion of the tube is increased. The 
increased secretion usually drains into the uterus, 
occasionally through the fimbriated extremity into 
the peritoneal cavity; but should the openings of 
the tube become occluded, it accumulates, causes 
distention of the tube, and a hydro-salpinx is 
formed. An acute catarrhal salpingitis may be- 
come chronic. 

In purulent salpingitis the inflammation is more 
severe and extensive. The inflammation begins in 
the mucous membrane, but soon involves all the 
structures in the tube walls. The epithelium is 
thrown off, the walls of the tube are infiltrated with 
serum and pus cells, and the fimbriated extremity 
is closed by adhesions of inflammatory lymph. 
The tubes are swollen, distorted, and adherent to 
the surrounding tissues as a consequence of the 
plastic exudate formed from an extension of the 



191 

inflammation to their peritoneal coverings. The 
tubes may be divided into separate cavities by the 
formation of adhesions within their lumen or by 
external adhesions constricting them. They are 
filled with a muco-purulent material, which, if the 
os uterinum remains open, may drain into the 
uterus, or it may accumulate in the tube and form 
a pyo-salpinx or leak into the peritoneal cavity and 
cause a peritonitis. This form of inflammation may 
also become chronic; but even should it not do so, 
the tube remains crippled, and is never as capable of 
performing its function as before. 

Chronic salpingitis, or interstitial salpingitis, may 
result from either of the preceding forms. It is 
caused by the infiltration of the tube walls by the 
products of inflammation and their organization into 
connective tissue. It usually leaves the tubes en- 
larged and distorted by adhesions and one or both 
(os abdominale usually) of its openings closed and 
its epithelium diseased or desquamated. A hydro- 
salpinx or a pyo-salpinx is not infrequent. 

The greatest danger of all forms of salpingitis is 
an extension to the peritoneum. This may occur 
by an extension of the inflammation directly 
through the walls of the tube or by the passage of 
the contents through the ostium abdominale. In 
rare cases it may take place from the rupture of a 
distended tube. The ovary is usually involved, and 



192 

may be the seat of one or more abscesses. If no 
more serious consequences result, the tube, ovary, 
and often the intestines, are matted together by 
adhesions. 

Symptoms. — In the acute cases these are masked 
by the accompanying uterine affection. Consider- 
able catarrhal, or even purulent, inflammation of 
the Fallopian tubes may exist without giving rise 
to marked symptoms. 

A peculiar colicky or burning pain in the iliac 
region of the affected side is often experienced. It 
is more severe at the menstrual period, and is in- 
creased by exercise, and especially by coition. 

The intermittent discharge of a muco-purulent 
fluid from the vulva is a very suspicious symptom. 
This is caused by the discharge of an accumulation 
of fluid in the Fallopian tube. It is also sometimes 
caused by an accumulation in the uterus or the 
vagina. 

Leucorrhoea is present, and the menstrual dis- 
turbances of endometritis. The general health de- 
teriorates, there is loss of flesh and strength, and 
there is slight fever at times, particularly if the sal- 
pingitis be purulent. 

Should the ovary be involved, there will be added 
the symptoms of ovaritis. 

For a diagnosis we must depend largely upon a 
physical examination. The tubes are swollen, ten- 



193 

der, distorted, adherent; and if filled with fluid, a 
pear-shaped tumor will be found. If they cannot 
be felt, a line of tenderness along their course is 
present, and tenderness will be caused by pressing 
the uterus toward the diseased side. If not in- 
volved, the ovary can be felt free of adhesions, ten- 
derness, and swelling. As it is almost invariably 
more or less affected, it will be found swollen, ten- 
der, involved in adhesions, and matted to the tubes. 

A recto-abdominal examination is of aid in -nak- 
ing a diagnosis. 

Prognosis. — If the disease be of the catarrhal type, 
the prognosis as to health is good, but sterility may 
result as an effect of the disease upon the tubes. 
The purulent variety sometimes proves fatal from 
involvement of the general peritoneal cavity or from 
gradually increasing invalidism. Sterility is a com- 
mon sequence of this form. Should the patient re- 
cover, she is predisposed to other attacks. 

Treatment. — In the acute stage the treatment is 
that of acute endometritis ; in the chronic stage it is 
often advisable to confine the patient to bed for two 
or three weeks. 

In no case should local treatments be given until 
all acute symptoms, particularly fever, have sub- 
sided ; and in every case, whether of examination 
or treatment, in which a tumor is situated in the 
pelvis that may possibly be caused by salpingitis, 



194 

all manipulations must be toward the uterus to pre- 
vent forcing any of the contents into the peritoneal 
cavity. 

In chronic cases the treatment outlined for 
chronic endometritis is indicated. Especial atten- 
tion should be given to the relaxation of adhesions 
about the tubes and ovaries, the manipulations al- 
ways being such as will force the tube contents in 
the direction of the uterus. 

HYDRO-SALPINX. 

This is the accumulation of a fluid which is nei- 
ther purulent nor bloody in the Fallopian tube. It 
is usually caused by a catarrhal salpingitis, the 
closure of both tubal openings, and the collection 
of the secretions of the tubal mucous membrane. 
The ostium abdominale is usually first to close, and 
fluid may accumulate when the ostium uterinum is 
only partially closed. 

The condition is bilateral, as a rule, and the tumor 
is rarely larger than an orange, though in excep- 
tional cases it may reach the size of a fetal head. 
It has thin walls, is slow in development, and fre- 
quently is movable. 

When a hydro-salpinx does not reach an extreme 
size, it rarely gives rise to symptoms. When symp- 
toms are produced, they are referable to the asso- 
ciated peritonitis and pressure. 



195 

On a bimanual examination, a sausage-shaped, 
sometimes tortuous, tumor is detected in Douglas' 
pouch, distinct from the uterus and extending from 
the uterine cornua outward. Fluctuation can some- 
times be detected; and if the ovary on the affected 
side is free, the diagnosis is more certain. 

Hydro-salpinx is most frequently mistaken for an 
ectopic gestation, an ovarian cyst, or a pyo-salpinx. 

In ectopic gestation there are the symptoms of 
pregnancy, a sudden and severe pain, perhaps 
the discharge of blood and the decidual membranes 
from the uterus, and the continued growth of the 
tumor. An ovarian cyst is spherical in outline; 
the ovary is not free, but is enlarged; and there is 
no connection between the tumor and the uterus. 

PYO-SALPINX. 

This is the accumulation of purulent material in 
the Fallopian tube. It follows purulent salpingitis, 
the agglutination of the fimbriated opening, and fre- 
quently also the uterine opening of the tube. 

Pyo-salpinx does not reach the extreme size of 
the largest hydro-salpinx, but grows more rapidly, 
and is attended by more or less peritonitis; hence 
the greater pain. The tube walls are thickened, 
but may be weakened by dilatation or disease; so 
that the possibility of rupture, peritonitis, and death 
is ever present. Rupture may occur into one of the 



196 

pelvic organs, into the peritoneal cavity, or exter- 
nally, but always with serious consequences. 

The enlarged, distorted, tender, and perhaps fluc- 
tuating, tumor may be felt low down in Douglas' 
pouch, usually immovable as a result of adhesions. 

The symptoms are vague pelvic pains and distress, 
failure of general health, or recurring attacks of 
slight peritonitis, with fever and slight chilly sen- 
sations or rigors. 

The differentiation from ectopic gestation and 
ovarian cysts is similar to that of hydro-salpinx. 
From hydro-salpinx it is differentiated by a history 
of puerperal or gonorrhoeal infection, greater con- 
stitutional disturbance, fixedness, tenderness, and 
occasional febrile attacks. 

HEMATO-SALPINX. 

This is a collection of blood, or hemorrhagic ma- 
terial, in the Fallopian tube. It may result from 
hemorrhage into a hydro-salpinx or a pyo-salpinx, 
the accumulation of menstrual blood, or hemor- 
rhage from other causes in a closed tube. 

It is of rare occurrence, unilateral, and often ac- 
companied by a bloody discharge from the uterus. 
Its differentiation from hydro-salpinx is very diffi- 
cult. 

Treatment, — The osteopathic treatment of these 
conditions depends upon the patency of the os uteri- 



197 

num. If this remain open, gentle strokings of the 
tube toward the uterus will empty the tube and 
effect a cure. Such manipulations must be very 
gentle ; and if the contents of the tube do not appear 
after a few treatments of this kind, the treatment 
must be stopped. If the case be one of pyo- salpinx, 
surgical measures should be used for its removal ; 
also in cases of hydro-salpinx or hemato-salpinx 
when they cause troublesome pressure symptoms. 



CHAPTER XIV. 



Diseases of the Tissues of the Pelvis. 

PELVIC PERITONITIS. 

This is an inflammation of any part of the perito- 
neum lining the cavity of the true pelvis or cover- 
ing the pelvic viscera. 

Causes. — Pelvic peritonitis is nearly always, if 
not always, secondary to disease of some pelvic 
organ, a purulent salpingitis in most instances. 

A severe endometritis may extend directly 
through the uterine walls or may infect the peri- 
toneum after first involving the connective tissue 
or lymphatics. 

Rupture of an ovarian abscess or a tubal abscess 
or a tubal pregnancy may be the cause. Instru- 
mental examinations or operations are not infre- 
quent causes; and in rare cases menstrual disturb- 
ances, as suppression from exposure to cold and 
wet, may result in peritonitis. 

The irritation of the retro-displaced uterus rub- 
198 



199 

bing against the peritoneum over the posterior pel- 
vic wall has produced a localized peritonitis. Tu- 
bercular pelvic peritonitis is usually secondary to 
similar disease of the tubes. 

A predisposing cause, by decreasing the nor- 
mal tissue resistance, is pelvic congestion, which 
results from osteopathic lesions, uterine or ovarian 
displacements, excessive venery, etc. 

Pathology. — The disease may be acute or chronic, 
and appears in a fibrinous, a serous, and a suppura- 
tive form, according to its severity. 

The first stage of a fibrinous peritonitis is con- 
gestion, the exfoliation of the endothelium, and the 
pouring out of a plastic exudate by which adhesions 
are formed, which may result in the matting to- 
gether of tube, ovary, omentum, or part of the in- 
testine into one mass. These adhesions frequently 
limit the inflammation and prevent the infection of 
the general peritoneal cavity. This exudate may 
become organized into permanent adhesions, which 
may cover the ovary, cause constriction and distor- 
tion of the tube, and even displacement of the ute- 
rus, but rarely ever are so firm and unyielding as 
the adhesions following cellulitis. 

In the serous form a fluid exudate predominates. 
If moderate in amount, it gravitates to Douglas' 
pouch, or it may be sufficient to fill the entire pel- 
vis. If the uterus is not fixed by adhesions, it 



200 

will be displaced forward by the fluid behind it ; but 
if fixed, the exudate may be in front of, or even 
above, it. 

The whole of the fluid may be absorbed and a 
cure result or may be only partially absorbed, there 
being sufficient plastic material to form adhesions. 
Occasionally a serous exudate in some way becomes 
infected, and a suppurative inflammation results. 

In suppurative peritonitis the focus of suppura- 
tion is usually limited by adhesions, so that the oc- 
currence of general peritonitis is rare. The suppu- 
rating area, or abscess, may open into some of the 
pelvic viscera or the peritoneal cavity, or it may 
pass through a sinuous tract and open externallly. 

Symptoms. — In acute pelvic peritonitis there is 
sudden pain, referable to the pelvis, which often ra- 
diates down the thighs. It may be moderate in 
severity, but is at times excruciating. There are 
chilly sensations or a decided chill, a rise of temper- 
ature, accelerated pulse, and nausea and vomiting. 
The hypogastrium is tender, distended, and vesical 
and rectal tenesmus are frequently present. 

The expression is one of anxiety. Delirium is not 
uncommon. 

The pain and temperature are very variable 
symptoms. Pain may be almost entirely absent ; 
the temperature may be normal, subnormal, or 
change from high to low degrees in a short time in 
very dangerous cases. 



201 

Suppuration is usually indicated by irregular 
chills, fever and sweats, and a slight yellow tinge to 
the skin ; but it may be present in the absence of 
these symptoms. 

Chronic peritonitis may develop so insidiously as 
to seem chronic from its beginning, which in some 
cases may be true. The patient is up, but suffers 
from menstrual derangements, particularly amen- 
orrhoea, menorrhagia, or leucorrhoea, and has con- 
stant pelvic pain and heaviness, which is aggra- 
vated by exertion, jolting, or coition. As the men- 
strual period approaches, the pain and discomfort 
increase. Recurrent acute attacks sufficiently se- 
vere to confine her to bed are occasional. These at- 
tacks are provoked by exertion, exposure to cold 
and wet, too violent or too frequent intercourse, 
and are very likely to occur near or during the men- 
strual period. 

There is a gradual failure of the general health 
and the development of nervous or hysterical ten- 
dencies. 

Physical Signs. — Should pus be suspected, the 
vaginal examination must be carefully and gently 
made for fear of causing an extension of the trouble 
by severing the newly-formed adhesions. During 
the first stage only exquisite tenderness of the vagi- 
nal vault and pain on movement of the uterus will 
be found. Later on, as serum or pus accumulates, 



202 

a soft, sometimes fluctuating, tumor will be felt in 
Douglas* fossa, which displaces the uterus ante- 
riorly. If the serum is absorbed, the vaginal vault 
becomes hard and indurated ; and the agglutinated 
tubes, ovaries, omentum, and intestine may be felt 
as a sensitive tumor at the side of or behind the 
uterus. In all cases the mobility of the uterus is 
impaired. 

When the case becomes chronic, there is tender- 
ness ; the agglutinated tubes, ovaries, and intestinal 
coils can be felt at the side of or behind the uterus; 
while in other cases the pelvic floor is so tender and 
indurated that the individual organs cannot be out- 
lined. 

Pelvic peritonitis is most often mistaken for cellu- 
litis, salpingitis, or hematocele. 

Cellulitis occurs usually after parturition, abor- 
tion, or an operation on the pelvic organs. The 
symptoms are less severe ; the tumor is not so large, 
and is situated close to the side of the uterus ; and 
if the disease extends, the swelling and tenderness 
remain along the walls of the pelvis, where the con- 
nective tissue is located. 

Salpingitis causes a sausage-shaped tumor, often 
bilateral, and can be felt running from the cornua 
of the uterus outward. 

Hematocele appears more suddenly. The first 
symptoms are those of hemorrhage rather than in- 



203 

fiammation, while the tumor is soft at first, and 
then becomes hard. 

In some cases the differentiation is impossible. 

Course and Prognosis. — Pus in the pelvis is a 
menace to life. When the disease is adhesive or 
serous, infection may occur; but the prognosis is 
better than when the trouble is primarily suppura- 
tive. If extensive adhesions form, constricting and 
deforming the tubes and covering the ovary, there 
is but little hope that the function of these organs 
will be restored; but there are good prospects of 
relieving the patient from chronic invalidism and 
enabling her to become an active woman. 

Treatment. — In the acute cases absolute rest is 
imperative. Pain must be relieved by inhibition of 
all centers having a sensory connection with the 
pelvis and by the proper use of hot or cold applica- 
tions. In the acute stages cold applications seem 
to have a better antiphlogistic effect, and an ice 
poultice may be applied to the hypogastrium and a 
continuous current of cold water run through the 
vagina. This is accomplished by the use of a con- 
tinuous-flow vaginal syringe, beginning with water 
of moderate temperature and gradually decreasing 
it until the desired temperature is reached. If the 
cold does not give relief or is not well borne, hot 
applications may be made in the same manner. The 
diet should be liquid and sustaining. 



204 

Elevations of temperature are controlled by the 
ordinary osteopathic and hydropathic means. Gen- 
tle manipulations of the extremities, legs especially, 
will have a derivative effect and quiet the patient. 

When the case becomes chronic and the pelvic 
viscera are matted together and fixed by adhesions, 
the indications are for relaxation and absorption of 
adhesions, separation of adherent organs, and the 
restoration of mobility. 

In accomplishing these ends, bimanual treatment 
is of first importance. It should be supplemented 
by removal of lesions, equalization of circulation by 
inhibition of the lower dorsal and lumbar regions, 
deep-breathing exercises, general treatment, and 
baths. The latter should not only be general, but 
warm Sitz baths, with the use of the vaginal bath 
speculum, are especially to be recommended. 

If pus is present and causing symptoms, the in- 
dications are for its evacuation, for which surgical 
measures are to be employed. 

PELVIC CELLULITIS. 

This is an inflammation of the subperitoneal con- 
nective tissue of the pelvis. This tissue is most 
abundant around the lower portion of the uterus, 
in the broad and sacro-uterine ligaments, and be- 
tween the cervix and the bladder ; and it is in these 
situations that the disease is most frequently lo- 



205 

cated. These locations are also more exposed to 
violence and infection. 

Cellulitis occurs in an acute and a chronic form. 

Causes. — Acute cellulitis may result from the in- 
juries following parturition or abortion, lacerations 
of the cervix extending to the connective tissue, 
endometritis by direct extension through the uterine 
walls, injuries from operations or instrumental ex- 
aminations, or too violent coition. It has in rare 
instances followed exposure to cold and wet. 

Continued pelvic congestion — as results from 
osteopathic lesions, displacements or disease of the 
pelvic organs, excessive sexual indulgence or ex- 
citement — not only predisposes to acute attacks, but 
is an actual cause of chronic cellulitis. 

Pelvic congestion is engorgement of blood ves- 
sels. This, if continued, is followed by extravasa- 
tion of serum and white blood cells and proliferation 
of connective tissue. This tissue undergoes a sec- 
ondary contraction, a process similar to that seen 
in cirrhosis of the liver. Chronic cellulitis is also 
caused by single or repeated acute attacks. 

Pathology. — During the first stages the connective 
tissue is swollen and infiltrated with serum and 
small, round cells. Resolution may occur in two or 
three weeks and recovery take place ; but should 
there have been a preexisting congestion, resolu- 
tion is not complete, the effused serum and cells 
undergo organization, and the case becomes chronic. 



206 

Again, the inflammation may proceed to suppura- 
tion, in which one large pus cavity or several small 
pus cavities may develop. 

In chronic cellulitis, following the contraction of 
the hyperplastic connective tissue, cicatricial bands 
are formed either around the cervix or along the 
course of the broad, sacro-uterine, or utero-vesical 
ligaments. As these bands contract, various uter- 
ine displacements are produced, according to the 
direction in which the organ is drawn. The cer- 
vical ganglion is involved in the formation of the 
cicatricial tissue, and to this is no doubt due the 
long train of reflex disturbances that so frequently 
follow displacements. The pelvic blood vessels, 
the veins especially, are constricted by the adhe- 
sions ; they become tortuous and dilated ; serum and 
white blood cells are extravasated ; and these, in 
turn, proliferate and form new tissue; so that the 
trouble is progressive and leads to congestion and 
pathological changes in all the pelvic structures. 

These connective tissue adhesions are a much 
more prolific source of displacements of the uterus 
than peritoneal adhesions, for the reason that the 
peritoneum is movable and does not so frequently 
anchor the uterus, and its adhesions are not so firm 
and are much more easily stretched than those 
formed of connective tissue. 

Occasionally, as a result of chronic suppurative 



207 

cellulitis, collections of pus are formed, which may 
remain in the pelvis or open by sinuous fistulae. 

Symptoms. — In the acute stages these are not so 
severe as in peritonitis. Pelvic pain is present, but 
is not so sudden in its onset or so severe as in peri- 
tonitis. An initial chill is frequent. There is a 
rise of temperature and an accelerated pulse. Irri- 
tability of the bladder and rectum may be present. 
Nausea and vomiting are not so common as in per- 
itonitis, and distention of the abdomen is rare. 
There are the usual accompaniments of fever — 
malaise, anorexia, headache, etc. 

In the chronic cases there are the evidences of 
displacement, pain, bearing-down sensations, fre- 
quently constipation and vesical irritability, and 
the train of diverse nervous symptoms seen with 
displacements. 

Physical Signs. — In the early stage of the acute 
trouble a vaginal examination reveals increased 
heat, tenderness, and a diffuse boggy tumor, usu- 
ally at the side of the uterus, which is displaced to- 
ward the oposite side. There may be a cumor on 
either side of the uterus connected by a swollen 
band in front of and behind the cervix. If the con- 
nective tissue in the sacro-uterine ligament is af- 
fected, the tumor will be behind the uterus, which 
will be displaced anteriorly ; and if along the utero- 
vesical ligament, the tumor is anterior, the displace- 
ment posterior. 



208 

Should pus form, the swelling becomes softer, 
though fluctuation is rarely detected. Movements 
of the uterus are painful. 

In the chronic form the uterus is found displaced 
toward the side on which the tumor was primarily 
located. It is fixed by adhesions which, on care- 
ful bimanual examination, can be felt. Attempts 
at moving the uterus stretch the adhesions and 
cause pain. Recto-abdominal examination is often 
of great service. 

Prognosis. — Life is rarely threatened in cases of 
cellulitis unless extensive suppuration develops, 
which is, fortunately, a rare occurrence. In the 
chronic form the adhesions are often firm and un- 
yielding, and the displacements and nervous symp- 
toms resulting are sometimes very obstinate and 
may require several months' treatment. All cases 
can be benefited, the majority being entirely re- 
lieved. 

Treatment. — This, in acute cases, is identical with 
the treatment of acute peritonitis. The indications 
for surgical measures are the same. 

In the chronic cases the treatment must be di- 
rected to the restoration of mobility and the relax- 
ation of adhesions. Owing to the firmer structure 
and larger size, the connective tissue adhesions re- 
quire more persistent treatment than those formed 
of peritoneum. 



209 

The same measures used for the cure of chronic 
peritonitis will be necessary in chronic cellulitis. 
Patience and persistence will be necessary in relax- 
ation of adhesions and correction of displacements. 

PELVIC HEMORRHAGE. 

Free hemorrhage, or hemorrhage into the perito- 
neal cavity and limited by adhesions, is called 
" hematocele ; " hemorrhage beneath the perito- 
neum and into the pelvic connective tissue is called 
" hematoma. " 

Causes. — Hematocele is caused in most instances 
by the rupture of a tubal pregnancy. Among the 
less frequent causes are rupture of a hemato-salpinx, 
torn peritoneal adhesions, intra-peritoneal rupture 
of a hematoma, excessive bleeding from a Graaffian 
follicle, which is usually itself caused by violent ex- 
ercise, coition, or exposure to cold or wet near or 
during the menstrual period. Constitutional dis- 
eases, accompanied by blood dyscrasia, may in rare 
instances be causative. 

The escaping blood gravitates to Douglas' pouch. 
If the bleeding is very sudden and profuse, death 
may occur in a short while. This, however, is un- 
usual ; for, as a rule, the hemorrhage is not suffi- 
cient to cause immediate death ; but its presence 
causes an adhesive peritonitis, by which adhesions 
are formed between the intestinal coils, and the 



210 

blood is walled off from the general peritoneal cav- 
ity. The blood may fill the recto-uterine pouch or 
may rise to or above the brim of the pelvis. At 
first the blood is thin, but it soon coagulates, and 
its liquid constituents are absorbed, so that it be- 
comes thick and dark. 

Symptoms. — There may be premonitory symp- 
toms, referable to the cause of the hemorrhage, or 
the onset may be sudden and unexpected. It be- 
gins with sudden pelvic pain, faintness, prostration, 
nausea or vomiting, rapid and weak pulse, pallor, 
cold extremities, anxiety; and if the hemorrhage is 
profuse, dyspnoea and vertigo will be present. 
Tympanites will be caused by the intestines being 
floated up by the blood. A feeling of pressure and 
heaviness in the pelvis is common. If the amount 
of the hemorrhage is large, rectal and vesical irrita- 
bility will be caused, also pressure symptoms of 
pain or edema of the legs. 

Following this attack, within from twenty-four to 
forty-eight hours there will be a rise of temperature, 
and usually a chill. This is due to inflammatory 
reaction, and lasts but a short while. Absorption 
of the blood clot may now take place, or the more 
unusual and more dangerous complication of infec- 
tion and suppuration may occur. 

In some cases bleeding occurs so gradually and 
slowly as not to give rise to acute symptoms. 



211 

Physical Signs. — Before the encapsulation or co- 
agulation of the blood the physical signs may not be 
distinct. On vaginal examination there is a sense 
of resistance in the recto-uterine fossa, the uterus is 
pushed forward, and the abdomen is tympanitic. 
After encapsulation or coagulation, a tumor, which 
seems to be molded into the recto-uterine space, 
will be felt, which, with the preceding symptoms, 
will usually make the diagnosis clear. In those 
cases in which Douglas' pouch is closed by adhe- 
sions the tumor may be anterior to or above the 
uterus. 

Hematoma is hemorrhage into the connective 
tissue, usually that between the layers of the broad 
ligament. Its causes are very similar to those of 
hematocele, tubal pregnancy being less frequently 
and violence more frequently a cause. Pelvic con- 
gestion, and the consequent engorgement of the 
blood vessels ramifying in the connective tissue, is 
an important predisposing cause. 

The amount of hemorrhage is less, owing to re- 
sistance of the connective tissue ; coagulation is not 
so rapid, and secondary inflammation is not so se- 
vere, as in hematocele. 

The symptoms are of much the same nature, but 
less violent than in hematocele. 

Physical Signs. — On examination, a distinct tumor 
is felt at the side of the uterus and in the anterior 



212 

segment of the pelvis, and the uterus is displaced 
and immobilized. If the bleeding is bilateral, a tu- 
mor will be felt on each side and connected around 
the cervix. In this case the uterus will be dis- 
placed upward. If a rectal examination be made, 
it will be found that the infiltration of blood into the 
connective tissue has caused an apparent stricture 
of this organ. 

Prognosis. — Should the hemorrhage be free into 
the peritoneal cavity, death may occur from shock, 
anaemia, or peritonitis. In encapsulated hemato- 
cele, recovery usually occurs in a few weeks or as 
many months. In hematoma the prognosis is still 
more favorable, owing to the smaller amount of 
hemorrhage and its extra-peritoneal situation. 

Suppuration may occur in either case and greatly 
retard recovery or prove fatal. 

Treatment. — No time should be lost in undressing 
the patient; but she should at once be put into a 
comfortable lying position, with her head low. Ab- 
solute quiet and inactivity are to be enforced ; ice 
bags are to be applied to the hypogastrium, a con- 
tinued current of cold water to the vagina, and hot 
applications to the extremities. These may be re- 
moved as soon as reaction is somewhat established, 
but the patient should be kept quiet for several days. 
Let the diet be liquid. 

If the case be diagnosed as intra-peritoneal rup- 



213 

turc of a tubal pregnancy, operative measures arc 
indicated; but if the hemorrhage be due to some 
other cause and there is no additional hemorrhage 
after three or four weeks, general treatment, warm 
general and Sitz baths may be given to promote 
absorption. After absorption is complete, any re- 
maining peritoneal adhesions may be relaxed by 
bimanual treatment. 

In the event of suppuration the pus should be 
evacuated. 



CHAPTER XV. 



Ectopic Gestation (Extra-uterine Pregnancy). 

This is the fixation of a fertilized ovum without 
the uterine cavity. It is estimated that it occurs 
once in every four or five hundred pregnancies. 

Causes. — Its cause is not absolutely known. It is 
believed that under normal conditions the fertiliza- 
tion of the ovum occurs near the ovarian end of the 
Fallopian tube, from which place it is carried to 
the uterine cavity by the cilia of the tubal epithe- 
lium. Consequently any condition of the tube or its 
mucous membrane which will hinder the passage 
of the ovum to the uterus will cause ectopic gesta- 
tion. Such conditions are stenosis or angles in the 
tube, chronic salpingitis, with loss of epithelium or 
its cilia. Some eminent authorities claim that in- 
vestigation has proven that a perfectly healthy tube 
is more likely to become the seat of an ectopic ges- 
tation than one which has been inflamed. However 
this may be, it is true that the disease often follows 
214 



215 

a period of sterility, and frequently there is a his- 
tory of previous trouble on the side upon which the 
tube becomes gravid. 

Ectopic gestation, or tubal pregnancy, is limited 
to no particular age within the childbearing limits 
and may occur with the first or any subsequent preg- 
nancy. In rare instances a uterine pregnancy has 
been complicated by a tubal pregnancy, or both tubes 
have been found pregnant, or a second tubal preg- 
nancy has been found several years subsequent to 
a first pregnancy. In still rarer instances the tube 
has been found to be the seat of a twin pregnancy. 

According to the location of the ovum, two varie- 
ties of ectopic gestation are recognized: 

i. Tubal, when the ovum is situated beyond the 
cornua of the uterus. 

2. Interstitial, when within that part of the tube 
traversing the uterine walls. 

The first of these varieties is by far the most fre- 
quent and important. 

These varieties have been much subdivided by 
some writers. 

As a result of the implantation of the ovum, the 
tube walls thicken by hypertrophy of their muscular 
structure; but as the fetus develops, they are 
thinned by distention and weakened by the in- 
growth of the villi of the chorion. As these changes 
are progressing, the ostium abdominale is gradually 



216 

closing until about the eighth week, when in most 
cases it is completely closed. In a few instances 
dilatation occurs. The os uterinum remains, open. 

As the fetus develops, the tension within the tube 
increases. If it be located near the fimbriated ex- 
tremity, the fetus may pass into the peritoneal cav- 
ity before the closure of the tube. This constitutes 
tubal abortion. After the closure of the ostium ab- 
dominale, rupture is inevitable and occurs between 
the third and twentieth weeks of pregnancy, usu- 
ally between the sixth and twelfth weeks. The rup- 
ture may take place through that part of the tube 
covered with peritoneum, in which case it is intra- 
peritoneal, or into the peritoneal cavity; or it may 
occur between the layers of the broad ligament, in 
which case it is extra-peritoneal, or without the 
peritoneal cavity. 

The immediate cause of the rupture is often a 
jar or jolt, straining, lifting, vaginal examination, 
or coition. In many cases no such exciting cause 
is found. 

With the lodgment of the ovum begins the devel- 
opment of the amnion, the chorion, and the fetal 
part of the placenta, the decidua vera developing in 
the uterus as though the pregnancy were normal. 
Owing to the abnormal and insecure attachment of 
the ovum to the tubal mucous membrane, hemor- 
rhage often occurs into the fetal membranes, which 



217 

causes separation of the chorionic villi and the 
death of the fetus either before or after rupture of 
the tube. In this case a tubal " mole " is formed. 
In a few cases the separation of the chorion is not 
complete or it gradually changes its location by- 
growth ; a placenta is formed ; and the fetus, having 
escaped from the tube, goes on to complete develop- 
ment. Under such conditions repeated hemor- 
rhages are to be feared. 

As a result of rupture, hemorrhage from the torn 
blood vessels occurs, which occasionally is sufficient 
to cause speedy death. If the rupture be intra- 
peritoneal, the blood gravitates to the recto-uterine 
space, where it coagulates and becomes encysted 
by peritoneal adhesions. If the rupture be extra- 
peritoneal, the blood is forced into the connective 
tissue of the broad ligament; and because of the 
resistance offered by this tissue the hemorrhage is 
not so profuse as in intra-peritoneal rupture, though 
in these cases a secondary rupture into the perito- 
neal cavity may occur. 

With the rupture of the tube, the ovum usually 
escapes with the blood; or if the rent be small, it 
may close it up and prevent further hemorrhage. 
The rupture of the tube usually terminates the life 
of the fetus ; but in some cases this is not so, and it 
goes on to complete development. When this oc- 
curs, labor sets in at term ; but as the child cannot 



218 

be delivered in the natural manner, its death from 
placental separation occurs. After its death, one 
of several changes may take place in it: the liquor 
amnii will be absorbed, as likewise may be the fluids 
of the fetal tissues, causing it to mummify; or lime 
ts may be deposited in the tissues, and it will 
become calcified and form a lithopedion, in which 
state it may remain for years; or it may undere a 
sort of fatty change and be converted into adipo- 
cere : or infection and suppuration may occur even 
a long while after the death of the fetus, an abscess 
may form, which may rupture into some of the pel- 
vic or abdominal organs, or externally, and dis- 
charge the fetal structures. 

Symptoms. — These are frequently vague and in- 
definite. There is, as a rule, a history of sterility 
for some time past or of a previous attack of en- 
dometritis. The usual symptoms and signs of preg- 
nancy are present; menstruation has been passed 
for several days or weeks : or there has been only 
a show at the regular time, which has been followed 
by an irregular, dark discharge. The reflex symp- 
toms of nausea and vomiting often begin early and 
are aggravated. 

Pressure symptoms develop early upon the af- 
fected side. The patient may be unable to lie on 
this side : and cramplike pains, originating in the 
iliac fossa and radiating down the thigh, are fre- 



219 

quently present. The presence and prominence of 
this pain are strongly suggestive of ectopic gesta- 
tion. 

A slight rise of temperature is often present, and 
the patient's general health is more impaired than 
it should be in a normal pregnancy. 

The patient may now have an attack of sudden, 
and often extremely severe, pain in one side of the 
abdomen, followed by faintness, prostration, pallor, 
rapid and feeble pulse, nausea or vomiting, dysp- 
noea, subnormal temperature, cold extremities, and 
a cold, clammy perspiration. These symptoms will 
depend in severity upon the amount of the hemor- 
rhage, and may prove fatal in a few hours; or, as 
is usually the case, recovery from the attack occurs ; 
but it may be repeated in a few days or weeks, with 
fatal results. 

With these symptoms there is in most cases an 
irregular hemorrhage from the uterus and the pas- 
sage of the decidual membranes. 

Physical Signs. — Before rupture occurs, an exam- 
ination reveals the uterus slightly enlarged and per- 
haps displaced laterally to a slight extent; the cer- 
vix is softened ; and the os is patulous — these, with 
the exception of the displacement, being the signs 
usually seen in pregnancy. The distended tube — 
as large as a hen's egg or a lemon, sensitive, elastic, 
and sometimes pulsating — may be felt to the side 
of, or slightly posterior to, the uterus. 



220 

After rupture the physical signs are those of he- 
matocele or hematoma, according as the rupture was 
intra-peritoneal or extra-peritoneal. 

Diagnosis. — Before rupture an absolute diagnosis 
is difficult, but the following are strongly presump- 
tive evidences: The signs and symptoms of preg- 
nancy, with early and aggravated reflex symptoms 
following a period of sterility; severe, cramplike 
pains in one side of the pelvis; departure, though 
slight, from the usual menstrual habit in regard to 
character, amount, or duration ; and the absence of a- 
history of gonorrhoeal or puerperal infection. Now, 
should the expulsion of the decidua from which the 
chorionic villi are absent, occur, the diagnosis is 
certain. 

At the time of rupture there is added to the his- 
tory given above sudden and severe pelvic pain, 
with the symptoms of shock and hemorrhage and 
the physical signs of hematocele or hematoma. 

Ectopic gestation is sometimes mistaken for a 
pyo-salpinx, a normal pregnancy with a fibroid tu- 
mor; and at the time of rupture, if the symptoms 
are not severe, it is mistaken for an ordinary abor- 
tion. 

In pyo-salpinx the history and signs of preg- 
nancy are not often present; the tumor is not so 
vascular or boggy and does not pulsate. After rup- 
ture there is no fall of temperature, but a steady 



221 

rise; the pain continues for a long time; there are 
no indications of a loss of blood; and septic symp- 
toms soon develop. 

In pregnancy with a fibroid tumor the enlarge- 
ment is less sensitive, harder, the uterus is enlarged 
proportionate to the stage of pregnancy; pain is 
absent until the tumor assumes large proportions 
and causes pressure on the surrounding organs; and 
symptoms of rupture do not occur. 

At the time of rupture the patient often believes 
herself pregnant, and the pain and menorrhagia 
lead her to believe that an abortion has taken place. 
She may continue to believe so until the occurrence 
of another hemorrhage. This mistake need not be 
made if the discharged decidua can be submitted 
to a competent microscopist. If the chorionic villi 
are found absent and a tumor is present at the side 
of the uterus, the diagnosis of ectopic gestation 
should be made. If the decidua cannot be obtained, 
a vaginal examination should be made; and if the 
tube is found swollen, tender, and elastic, the phy- 
sician should be on his guard. 

Prognosis. — If unmolested, about two-thirds of all 
cases die. The remaining one-third who recover are 
frequently left chronic invalids. 

Treatment. — At the time of rupture the treatment 
is identical with that of hematocele. If a diagnosis 
of extra-peritoneal rupture can positively be made, 



222 

the further treatment is that of hematocele; but if 
the hemorrhage is intra-peritoneal, surgical measures 
to ligate the bleeding vessels and remove the rup- 
tured tube and products of conception should be 
resorted to as soon as the patient has sufficiently 
recovered from the shock. 



IISTDEX. 



Adhesions 17, 48 

Relaxation of 125 

Amenorrhcea '. 64 

Anteflexion 120 

Anteversion 126 

Arbor Vitae 22 

Areolar Hyperplasia 108 

Articulations 9, n, 12 

Nerve Supply of n, 12, 13 

Auscultation 44 

B 

Backward Displacements..... 130 

Bartholin's Glands 28 

Bimanual Examination..., 47 

Broad Ligaments 24 

Bulbs of Vestibule 29 

c 

Canal of Nuck 28 

Cancer (See Carcinoma) of Ovary 187 

Carcinoma of Uterus .... 151, 158 

Carunculse Myrtiformes 29 

Cellulitis, Pelvic 204 

Cervico-uterine Ganglion 31 

Cervix 20 

Chancroid 88 

Change of Life. , 57 

Climacteric 57 

Clitoris 29 

Hypertrophy of 82 

Cystocele 97 

Cysts of Ovary 174 

D 

Dermoid Cysts 177 

Displacements of Uterus 119 

Dorsal Position 43 

223 



224 

Douglas' Pouch 17 

Dysmenorrhea 70 

E 

Ectopic Gestation 214 

Endometritis, Acute 102 

Chronic ... 106 

Endometrium 21 

Erosion of Os 107 

External Generative Organs 27 

External Os 20 

Extra-uterine Pregnancy 214 

F 

Falling of Womb 136 

Fallopian Tubes 26 

Nerves of 32 

Fibroid Tumors of Ovaries 187 

of Uterus 144 

Fibro-myomata 144 

Flexion 120 

Fossa Navicularis , 30 

Fourchette 28 

G 

Glandular Cysts 176 

Graaman Follicles 26 

Granular Os 107 

H 

Hematocele 209 

Hematoma .... 209 

Hemato-salpinx ... 196 

Hemorrhage, pelvic 209 

Hermaphrodism .v 83 

Herpes Progenitalis 84 

Hooded Clitoris 82 

Hydro-salpinx 194 

Hypogastric Plexus 30 

Hymen ........ 29 

Absence of , 82 

I 

Imperforate Hymen.. 82 

Inferior Hypogastric Plexus 31 

Inspection of Abdomen 43 

Internal Os ... 20 

Intra-vaginal Examination ... 45 

Intravaginal Treatments 50 

Contraindications 53 

Frequency 52 

Technic 50 



225 



L 

Labia, Atresia of 83 

Hypertrophy of 82 

Labia Majora 28 

Labia Minora 28 

Labial Varicocele 89 

Lacerations of Cervix 114 

Consequences 114 

Lateral Displacements 120 

Leucorrhcea 78 

Levator Ani 15 

Ligaments of Uterus 23 

Local Treatments 5o 

M 

Malignant Tumors of Uterus. 151 

Membranous Dy sinen orrhcea 72 

Menopau se 57 

M e norrh agia 75 

Menstruation... 54 

Mensuration 44 

Metritis 103 

Chronic Parenchymatous 108 

Metrorrhagia 77 

Mons Veneris .,..,... 27 

Muscular Contractures 38 

N 

Neoplasms of Ovary 174 

of Uterus , 144 

Nerves to Bladder 31 

to Fallopian Tube ... 32 

to Ilio-femoral Articulation 13 

to Ovaries 32 

to Perineal Region 20 

to Sacro-coccygeal Articulation 12 

to Sacro-iliac Articulation 11 

to Uterus 31, 32 

to Vagina 31, 32 

to Vulva 33 

o 

Oophoritis 167 

Oral Examination. 34 

Osseous Lesions 38 

Osteopathic Centers 32 

Examination 37 

Os Uteri 20 

Ovarian Apoplexy. 163 

Plexus 30 



226 



Ovaries ,. 25 

Absence of.. .... 161 

Congestion of 162 

Cysts of . ..... . , 174 

Diseases of 161 

Displacements of.. .. 164 

Nerves of 32 

Position of 25, 26 

Prolapse of 1 64 

Rudimentary 161 

Structure of , 26 

Supernumerar}^ i6r 

Ovaritis Acute 167 

Chronic . i6v» 

Ovules of Naboth 21 



Palpation 44 

Papillary Cysts 176 

Pelvic Articulations 9 

Brain , 31 

Cellulitis 204 

Connective Tissue 16 

Diaphragm , 15 

Fascia 15 

Hemorrhage.. 209 

Peritoneum 17 

Adhesions of ..... 18 

Peritonitis 198 

Skeleton 9 

Percussion .. 44 

Perineal Body iq 

Region 18 

Septum 19 

Peri-ovaritis - = .. 167 

Physical Examination 42 

Position of Uterus. 22 

of Ovary 25, 26 

vSim's. 43 

Dorsal... 43 

Posterior Commissure 2S 

Precocious Menstruation 62 

Procidentia 136 

Prolapse of Ovaries 164 

o Uterus.... . 136 

of Vaginal Walls 97 

Proliferating Cysts , 175 

Pruritus Vulvae . 86 

Psoas Magnus Muscle ,...,- 14 

Pudendal Hydrocele 90 

Pudendal Hernia... . 90 



227 

Pyosalpinx 195 

Pyriformis Muscle i4 

R 

Rectocele 97 

Replacement of Uterus 126, 129, 134, T41 

Retroflexion 1 30 

Retroversion 130 

Rima Fudendi 28 

Rotary Lesions 39 

Round Ligaments 24 

s 

Sacro-sciatic Foramina 11 

Sacro-uterine Ligaments 23 

Relaxation of 129 

Salpingitis, Acute 189 

Catarrhal 189 

Chronic 191 

Interstitial 191 

Purulent 189 

Sarcoma of Ovary.. ., 187 

of Uterus 158 

Secondary Lesion 38 

Simple Cysts 175 

Sims' Position ....... -. 43 

Solid Tumors of Ovary 187 

Subinvolution 117 

Superin volution 118 

Suppression of Menses 64, 65 

u 

Urethral Caruncle 87 

Uterus 20 

Absence of 101 

Atresia of . 102 

Atrophy of , 118 

Displacements of 119 

Infantile 102 

Ligaments of 23 

Mobility 23 

Nerves of 31, 32 

Position 22 

Replacement of 126, 129, 134, 141 

Size 22 

Uterus Bicornis 101 

Uterus Didelphys 102 

Uterus Septus 102 

Uterus Unicornis 101 



228 



V 

Vagina 27 

Absent 92 

Atresia of 92 

Diseases of 92 

Double 92 

Foreign Bodies in 100 

Injuries to .. . 99 

Malformations of 92 

Nerves of..... 31, 32 

Stenosis of... 92 

Vaginal Examination 45 

Fistulae 96 

Treatments. . 50 

Vaginismus 96 

Vaginitis 92 

Varicocele of Labia 89 

Venereal Warts.. 88 

Version 120 

Vesico-uterine Ligaments 23 

Vestibule.. , 29 

Vicarious Menstruation 63 

Vulva 27 

Cutaneous Affections of 83 

Injuries to 9I 

Nerves of 33 

Tumors of 90 

Vulvitis 84 

Vulvo-vaginai Glands 28 

Abscess of 89 

Cysts of 89 



OCT 



9 1902 



902 



